



Book 



GqfiyriglrtN?. 



COKFIGHT DEPOSIT. 



Aj 



ENLARGEMENT OF THE PROSTATE 






DEAVER 



J 



v \ ) 



By the Same A ut hor 



Surgical Anatomy 



A Treatise on Human Anatomy in its 
Application to the Practice of Medicine 
and Surgery. With 499 Full-page Illus- 
trations, engraved from original drawings, 
made by special artists, from dissections 
prepared for the purpose in the dissecting 
rooms of the University of Pennsylvania. 
Three Royal Square Octavo Volumes. 

Half Morocco or Sheep, $30.00 
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Surgical Anatomy of the Head 
and Neck 

With 177 Full-page Plates, nearly all of 
which have been made from special dissec- 
tions. Royal Octavo. Half Morocco, $12.00 



Appendicitis 



Its History, Anatomy, Clinical ^Eti- 
ology, Pathology, Symptomatology, 
Diagnosis, Prognosis, Treatment, Tech- 
nique of Operations, Complications and 
Sequels. Third Edition, Thoroughly Re- 
vised and Enlarged. With sixty-four full- 
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Cloth, $7.00; Half Morocco, $8.00 



Surgery of the Upper Abdomen 

Surgical Diseases of the Stomach ; Duo- 
denum ; Pancreas ; Liver, its Ducts, in- 
cluding Gall-Stones. Their Diagnosis, 
Technique of Operations, and After- 
Treatment. Fully Illustrated. 

In Preparation 



ENLARGEMENT 
OF THE PROSTATE 



Its History, Anatomy, ^Etiology, Pathology, Clinical 
Causes, Symptoms, Diagnosis, Prognosis, Treat- 
ment, Technique of Operations, 
and After-treatment 



BY 

JOHN B. DEAVER, M.D. 

Surgeon-in- Chief to the derman Hospital, Philadelphia 
ASSISTED BY 

ASTLEY PASTON COOPER ASHHURST, M.D, 

Surgeon to the Out-Patient Department of the Episcopal Hospital : Assistant 

Surgeon to the Orthopedic Hospital, and to the Dispensary 

of the German Hospital 



ILLUSTRATED WITH 108 FULL-PAGE 
PLATES AND A COLOURED FRONTISPIECE 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
1905 



-V 



V^ fc 



LIBRARY of OONGRESS 


Twc Copies 


rteceiveu 


MAY 15 


iyu5 


GLASS «*^ 

COPY 

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entry 


XXC. Not 

oo 

8. 



Copyright, 1905, by P. Blakiston's Son & Co. 



PRESS OF 

WM. F. FELL COMPANY 

1220-24 Sansom Street 

philadelphia. pa. 



TO 



JAMES TYSON 

?=:-5S5:p :.= 1 -.z::;:--h ;v ?:-: = .'-. = -;;--: :- ?=nnsylvan:a 

IX EVIDENCE OF MY HIZH APPRECIATION 3? KIM AS AN ACCCMPLISHEE PHYSICIAN 

OF HIS WELL KNO'A'N WC?H< IN ZISEaSES OF THE J-?z? C-ENITO-VRINaR^: 

FRACT AXE AS A TRUSTEE FRIEND 



PREFACE. 



The surgery of the prostate gland has acquired within the 
last few years such a conspicuous position in both surgical litera- 
ture and practice, that the publication of another text-book on 
the subject can scarcely be a matter of surprise. And as the 
author has had considerable experience, both operative and 
otherwise, with prostatics, it was not unwillingly that he com- 
plied with the request of his publishers to write a monograph 
on this subject. 

In preparing this volume, the aim has been to produce a 
work fully representative of the subject of which it treats. While 
the results of the author's own experience have been included, 
he has taken pains not to remain uninformed of the opinions 
of other surgeons. A conscientious search and study of pros- 
tatic literature has therefore been made, to the end that no per- 
sonal bias should infect the principles of diagnosis and treatment 
which it has been endeavoured to inculcate. The present work, 
therefore, claims to be more than a mere compilation of the ideas 
of others; the author has not hesitated to hold his own opinions 
when these have seemed preferable, and he has tried to present 
the reasons for these opinions in such a way as to command 
the attention which he thinks they deserve. 

The illustrations have been chosen with great care. They 
are in most cases original, but where it proved impossible to 
obtain original material, selection has been made of those which 
most nearly presented the requisite characteristics. Although an 
attempt has been made — and, the author ventures to think, not 
without success — to illustrate every important phase of pros- 
tatic surgery, both pathological and clinical, as well as opera- 



Vlll 



Preface. 



tive, yet in no instance has a plate been introduced which was 
not considered illustrative of the text. All the illustrations 
have been drawn by Mr. C. F. Bauer, except the microscopical 
plates, which were prepared by Mrs. J. D. Z. Chase, under the 
direction of Dr. A. O. J. Kelly. 

The treatment, other than operative, has been discussed in 
greater detail than may seem warranted to some; but realizing 
that this forms by far the largest part of actual practice, it has 
seemed wise to the author to consider it at length. 

In concluding a work which has occupied much of his time 
for over a year, the author desires to express a hope that the 
volume will prove of real value to those surgeons and family 
physicians who have prostatics under their care, and will serve 
in some little degree to elucidate the principles of surgical treat- 
ment of one of the most distressing maladies of mankind. 

1634 Walnut Street, 
May, 1905. 



CONTENTS. 



PAGE. 

Description of the Plates, xi 

Chapter I, i 

History and Literature. 

Chapter II, 20 

Embryology; Comparative Anatomy; Gross and Microscopical 
Anatomy; Relational or Applied Anatomy; and Physi- 
ology. 

Chapter III, 46 

Pathology and Etiology. 

Chapter IV, 72 

Clinical Pathology: Effects on Urethra, Bladder, Kidneys, Urine, 
and Rectum. 

Chapter V, 84 

Clinical Causes: Race, Age, Occupation, Social Habits, Previous 
Diseases. 

Chapter VI, 92 

Subjective Symptoms. 

Chapter VII, 100 

Objective Symptoms — Physical Examination. 

Chapter VIII, 108 

Diagnosis and Differential Diagnosis ; Prognosis. 

Chapter IX, 121 

Treatment: Constitutional; Catheterism; Prevention of Com- 
plications ; and Treatment of Complications. 

Chapter X, 166 

Local Palliative Treatment, Including Urinary Fistula, the 
Bottini Operation, and Castration. 

Chapter XI, 200 

Indications for Radical Treatment by Suprapubic and by Peri- 
neal Prostatectomy. 

Chapter XII, , 215 

Technique of Operations, Including the Preparation of the 
Patient, with the After-treatment. 

Bibliography, 243 

Index of Names, .- 253 

General Index, 257 



DESCRIPTION OF THE PLATES. 



Frontispiece. page . 

Plate I, 2 

Tunneling the Prostate in a Case of Urinary Obstruction (Cru- 
veilhier) . 

Plate II, 4 

Harrison's Olivary Bougies for Systematic Compression of the 
Enlarging Prostate. 

Plate III, 6 

Mercier's Prostatotome and Prostatectome. 

Plate IV, 8 

Sir Henry Thompson's Instruments for Establishing a Suprapubic 
Urinary Fistula. 

Plate V, 10 

Tapping the Bladder from the Perineum in the Case of an En- 
larged Prostate (Ashhurst). 

Plate VI, 20 

Developement of the Genito-urinary Tract. 

Plate VII, 22 

Fcetal Prostate from a Six Months Fcetus in the Museum of the 
German Hospital. 

Plate VIII, 24 

Developement of the Aponeurosis of Denonvilliers (Cuneo and 
Veau) . 

Plate IX, 26 

Testes, Prostates and Protometra of the Goat (Owen). 

Plate X, 27 

Accessory Male Glands and Protometra of Hyaena Striata 
(Owen). 

Plate XI, 28 

Congenital Absence of the Left Vas Deferens and Seminal 
Vesicle, associated with Imperfect Developement of the 
Prostate on the Side Affected (Socin after Launois). 

Plate XII, 29 

Median Sagittal Section of the Pelvis and Lower Abdomen, show- 
ing the General Relations of the Prostate to the Bladder, the 
Urethra and the Rectum. 

Plate XIII, 30 

Transverse Section of the Pelvis and Prostate. 

Plate XIV, 36 

Urethra and Bladder Laid Open from Above. 

xi 



xii Description of the Plates. 

PAGE 

Plate XV, 36 

Diagram of Sheath of the Prostate in Sagittal Section. 

Plate XVI, 37 

Diagram of Sheath of the Prostate in Transverse Section. 

Plate XVII, 37 

Diagram to show the Dilatability of the Various Parts of the 
Urethra. 

Plate XVIII, 37 

Coronal Section of the Pelvis through the Prostate (Spalteholz). 

Plate XIX, 37 

View of the Base of the Bladder and the under Surface of the 
Prostate. 

Plate XX, 40 

Side View of a Dissection of the Pelvis showing the Fasciae around 
the Bladder and the Prostate (after Proust). 

Plate XXI, 41 

The Same, showing Relations of the Muscles after the Various 
Layers of Fascia have been Removed. 

Plate XXII, 42 

Side View of the Pelvis showing the Relations of the Peritoneal 
Reflections when the Bladder is Empty and when it is Dis- 
tended (Gerrish). 

Plate XXIII, 42 

Surgical Anatomy of the Perineum: the Superficial Muscles. 

Plate XXIV, 42 

Surgical Anatomy of the Perineum: the Superficial Layer of the 
Triangular Ligament. 

Plate XXV, 43 

Surgical Anatomy of the Perineum: the Deep Vessels and 
Nerves and the Deep Transverse Perineal Muscles. 

Plate XXVI , 44 

Surgical Anatomy of the Perineum: the Membranous Urethra. 

Plate XXVII, 44 

Surgical Anatomy of the Perineum: the Levator Ani. 

Plate XXVIII, 44 

Surgical Anatomy of the Perineum: the Prostate Exposed. 

Plate XXIX, 48 

Under Surface of an Enlarged Prostate, weighing 145 Grammes 
(about 5 Ounces). 

Plate XXX, 49 

Upper Surface of an Enlarged Prostate, weighing 145 Grammes 
(about 5 Ounces). 

Plate XXXI, 50 

Enlarged Prostate weighing 30 Grammes (1 Ounce). 

Plate XXXII, 52 

Enlarged Prostate (No. 1533). 



Description of the Plates. xiii 



PAGE. 



Plate XXXIII, 54 

Enlarged Prostate (No. 1469). 
Plate XXXIV, 55 

Enlarged Prostate (No. 1555), weighing if Ounces. 

Plate XXXV, 56 

Enlarged Prostate (No. 1623), weighing 4 Ounces. 

Plate XXXVI, 57 

Cut Surface of Enlarged Prostate (No. 1623). 

Plate XXXVII, 58 

Upper Surface of Enlarged Prostate (No. 1542), weighing 4 
Ounces. 

Plate XXXVIII, 58 

Under Surface of Enlarged Prostate (No. 1542). 

Plate XXXIX, 58 

Cut Surface of Enlarged Prostate (No. 1542). 

Plate XL, 59 

Enlarged Prostate weighing 100 Grammes (3 J Ounces). 

Plate XLI, 60 

Enlarged Prostate (No. 2138), weighing 5 J Ounces. 

Plate XLII, 60 

Enlarged Prostate (No. 2138). 

Plate XLIII, 61 

Enlarged Prostate (No. 1826), weighing 56 Grammes. 

Plate XLIV, 62 

Under Surface of Enlarged Prostate (No. 1826). 

Plate XLV, 65 

Microscopical Section from Prostate No. 1502, showing Con- 
siderable Hyperplasia and some Dilatation of the Glandu- 
lar Structure. 

Plate XLVI, 66 

Micro photograph from Prostate No. 1258, showing Marked Glan- 
dular Hyperplasia. 

Plate XLVII, 67 

Microscopical Section from Prostate No. 1623, showing Cystic 
Dilatation of the Acini. 

Plate XLVIII, 68 

Microscopical Section from Prostate No. 1542, showing both 
Glandular Hyperplasia and Fibrous Overgrowth in the 
Same Microscopical Field. 

Plate XLIX, 69 

Microscopical Section from Prostate No. 1542, showing Marked 
Connective Tissue Hyperplasia. 

Plate L, 72 

Sagittal Section showing Elevation of the Vesical Orifice of the 
Urethra and the Formation of a Retro-prostatic Pouch. 



xiv Description of the Plates. 



PAGE. 



Plate LI, 73 

Urethra Laid Open from Above, showing Lateral Deviation of 
the Prostatic Portion from Unequal Enlargement of the 
Lateral Lobes of the Prostate (Anger). 

Plate LII, 74 

The same, showing a Y-shaped Prostatic Urethra due to the 
Presence of a Pedunculated "Median Lobe" (Cruveilhier). 

Plate LIII, 75 

Sagittal Section through the Prostatic Urethra showing Great 
Overgrowth of the Parts beneath the Urethra, Obliterating 
the Subpubic Curve (Anger). 

Plate LIV, 76 

View of an Enlarged Prostate from within the Bladder, showing 
"Cervix Uteri" Enlargement (Socin and Burckhardt). 

Plate LV, 77 

Bar at the Neck of the Bladder (Watson). 

Plate LVI, 78 

Dilated Atonic Bladder, with Enlargement of the Prostate. 
(From a specimen in the Mutter Museum of the College of 
Physicians of Philadelphia.) 

Plate LVII, 80 

Contracted Infected Bladder, with Enlargement of the Prostate. 
(From a specimen in the Mutter Museum of the College of 
Physicians of Philadelphia.) 

Plate LVIII, 82 

Dilatation of the Ureters from Enlargement of the Prostate. 
(From a specimen in the Museum of the Pennsylvania Hos- 
pital.) 

Plate LIX, 104 

Combined Examination, with a Catheter in the Bladder and a 
Finger in the Rectum. 

Plate LX, , 128 

Soft-rubber (Nelaton) Catheter. 

Plate LXI 130 

Figs. 1 and 2. — Metallic Catheters with Prostatic Curves. 

Fig. 3. — Mercier's Elbowed Catheter. 

Fig. 4. — Mercier's Double Elbowed Catheter. 

Plate LXII, 131 

Diagram of the Subpubic Curve of the Urethra (Van Buren and 
Keyes) . 

Plate LXIII, 132 

Fig. 1. — Catheter with Caoutchouc bridle attached, to facilitate 

its Retention in the Bladder. 
Fig. 2. — English Catheter Moulded on an Over curved Stylet, 
by which its Curve can be Altered at Will. 

Plate LXIV, 134 

Portable Catheter Case. 



Description of the Plates. xv 

PAGE. 

Plate LXV, 136 

Portable Catheter Cases. 
Plate LXVI, 1 68 

McGuire's Suprapubic Fistula and Obturator (Ashhurst). 

Plate LXVII, 170 

Fig. 1. — Stevenson's Suprapubic Drainage Tube. 
Fig. 2. — Senn's Sigmoid Catheter for Use in a Suprapubic 
Fistula. 

Plate LXVIII, 172 

Stevenson's Suprapubic Drainage Tube in Use (after DaCosta). 

Plate LXIX, 174 

Senn's Sigmoid Catheter in Use (DaCosta). 

Plate LXX, 176 

Fig. 1. — Owens's Perineal Tube. 
Fig. 2. — Watson's Perineal Tube. 

Plate LXXI, 188 

The Bottini Apparatus. 

Plate LXXII, 190 

Freudenberg's and Young's Incisors for the Bottini Operation. 

Plate LXXIII, 192 

The Bottini Incisor in Use (after Socin and Burckhardt). 

Plate LXXIV, 194 

Diagram of Incisions used in the Bottini Operation. 

Plate LXXV, 196 

Incisions in the Prostate made in the Bottini Operation, seen 
from within the Bladder (Socin and Burckhardt). 

Plate LXXVI, 219 

Suprapubic Prostatectomy: the Skin Incision. 

Plate LXXVII, 220 

Suprapubic Prostatectomy: Separating the Fibres of the Rectus 
Muscle with the Handle of the Scalpel. 

Plate LXXVIII, 221 ' 

Suprapubic Prostatectomy: the Bladder is Exposed, and 
Steadied with a Tenaculum. 

Plate LXXIX, 222 

Suprapubic Prostatectomy: the Bladder has been Opened and 
an Incision has been made through its Mucous Membrane 
over the Prostate. 

Plate LXXX, 224 

Suprapubic Prostatectomy: Sagittal Section of the Pelvis show- 
ing the Finger Enucleating the Prostate, as Counter-pressure 
is made in the Perineum and Rectum by the Fingers of the 
Other Hand. 

Plate LXXXI, 225 

Suprapubic Prostatectomy: Appearance of the Parts after the 
Prostate has been Removed. 



xvi Description of the Plates. 



PAGE. 



Plate LXXXII, 226 

Suprapubic Prostatectomy: Method of Checking Haemorrhage 
by Packing the Cavity from which the Prostate has been 
Enucleated. 

Plate LXXXIII, , 228 

Suprapubic Prostatectomy: Drainage-tube and Dressing in 
Place. 

Plate LXXXIV, 230 

Perineal Prostatectomy: Proust's Inverted Perineal Position. 

Plate LXXXV, 231 

Perineal Prostatectomy: Transverse Skin Incision. 

Plate LXXXVI, 232 

Perineal Prostatectomy (Proust) : Division of the Recto-urethral 
Muscle. 

Plate LXXXVII, 232 

Perineal Prostatectomy (Proust): Aponeurosis of Denonvilliers 
Opened. 

Plate LXXXVIII, 233 

Perineal Prostatectomy (Proust) : Method of Enlarging the Field 
of Operation with the Fingers. 

Plate LXXXIX, 233 

Perineal Prostatectomy (Proust) : Separating the Sheath of the 
Prostate from its Capsule. 

Plate XC, 234 

Perineal Prostatectomy (Proust): Hemisection of the Prostate. 

Plate XCI, 234 

Perineal Prostatectomy (Proust): Dissecting the Prostate off 
the Urethra. 

Plate XCII, 235 

Perineal Prostatectomy (Proust): Suturing the Floor of the 
Urethra. 

Plate XCIII, 236 

Perineal Prostatectomy : Skin Incisions — the Inverted Y and the 
Inverted V Incisions. 

Plate XCIV, 236 

Young's Two-bladed Prostatic Tractor. 

Plate XCV, .--;-* 2 3 6 

Fig. 1. — Young's Prostatic Tractor in Use, seen from within the 
Bladder. 

Fig. 2. — Diagram showing the Portions of the Prostate Removed 
in Young's Operation of "Conservative Perineal Prostatec- 
tomy." 
Plate XCVI, 237 

Perineal Prostatectomy (Young) : Incisions into the Prostate. 

Plate XCVII, 238 

Perineal Drainage with Continuous Irrigation (after Young). 



Description of the Plates. xvii 



PAGE. 



Plate XCVIII, 238 

Fig. 1. — Ferguson's Prostatic Depressor. 

Fig. 2. — Syms's Rubber Bulb Tractor for Perineal Prostatec- 
tomy. 

Fig. 3. — The Same with its Bulbous Extremity Distended. 
Plate XCIX, '. 238 

Syms's Rubber Bulb Tractor in Use. 
Plate C, 239, 

Murphy's Hooks for Perineal Prostatectomy. 
Plate CI, 240 

Perineal Prostatectomy: Skin Incisions — the Straight Median 
Incision, and Dittel's Incision. 
Plate CII, 240 

Perineal Prostatectomy: Straight Median Incision, Exposing 
Colles's Fascia. 
Plate CHI, 240 

Perineal Prostatectomy: Colles's Fascia has been Opened. 
Plate CIV, 240 

Perineal Prostatectomy: Membranous Urethra Exposed. 
Plate CV, 240 

Perineal Prostatectomy: Membranous Urethra Opened. 
Plate CVT, 240 

Perineal Prostatectomy: the Prostate Exposed. 
Plate CVH, 240 

Perineal Prostatectomy: the Prostate is being Enucleated with 
the Aid of Murphy's Hooks as Tractors. 
Plate CVIII, 241 

Perineal Prostatectomy: Drainage-tube Introduced and Wound 
Dressed. 



ENLARGEMENT OF THE PROSTATE 



CHAPTER I. 
HISTORY AND LITERATURE. 

It is a remarkable thing that any part of the human body 
liable to such important pathological changes as the prostate gland 
should have acquired a conspicuous place in surgery within 
such comparatively recent years. Its very existence was unknown 
until the beginning of the sixteenth century, and it is only within 
the short space of a decade that its operative surgery has been 
deemed of sufficient magnitude to require exposition in mono- 
graphs of any size. 

The symptoms of this malady, if we may believe Sir Everard 
Home [123],* have been recognized from time immemorial. This 
ingenious author surmised that the enlargement of the prostate 
gland met with so universally in old age is " alluded to in the 
beautiful description of the natural decay of the body, in the Bible, 
in the book of Ecclesiastes, the 12th chapter, the 6th verse, 
where it is written, 'or the pitcher be broken at the fountain, or 
the wheel broken at the cistern/ Expressive of the two principal 
effects of this disease, the involuntary passing of the urine, and 
the total stoppage." 

From scattered observations among the works of the classic 
authors it appears that these writers considered that patients 
with prostatic hypertrophy suffered from " excrescences " or 
"carnosities" at the neck of the bladder; and that when these 
outgrowths offered obstruction to the evacuation of the bladder 

* The figures throughout the text enclosed in brackets [thus] refer to the correspond- 
ing numbers in the Bibliography, pages 243 to 252. 
2 P 



2 History. 

their destruction was attempted with metallic instruments, intro- 
duced, of course, through the penile urethra. Certain of the 
ancient authors recommended incision of the neck of the blad- 
der through the perineum in patients with retention of urine who 
were " nearly dying with the pain," when the urethra was much 
inflamed, and therefore impassable to the catheter, even if no 
calculus existed to serve as an excuse for lithotomy; but it is 
not known that they actually performed such an operation. 

The ignorance of the ancients as to the anatomical existence 
of the prostate may be explained on the hypothesis that they 
did not practise dissection of the human body. According to 
Galen [94], Herophilus first employed the term " prostate," 
which he, however, appears to have applied to the seminal vesi- 
cles (adevoetdeu yrpoffTdrat, "prostatas glandulosae"), while the term 
xtpffoetdeis izpo<TTdzai, "prostatas cirsoides," appears to have repre- 
sented the ampullae of the vasa deferentia. It should be recalled, 
to excuse Herophilus for his apparent confusion of terms, that 
the prostate gland of the lower domestic animals, as well as 
that of monkeys, is a bifid organ, much resembling in some cases 
the human seminal vesicles. 

Except for this brief reference, no mention whatever of the 
prostate gland is to be found until the sixteenth century. Its 
discovery is attributed to Nicolo Massa, a Venetian physician, 
who died in 1563. Riolanus [200], about the middle of the six- 
teenth century, was the first to suggest that the bladder could 
be obstructed by a swelling of the prostate. In several cases of 
urinary retention this surgeon successfully practised incision of 
the neck of the bladder through the perineum, but it is not re- 
corded whether the cause of the retention was enlargement of 
the prostate gland. 

John Hunter [128], Sir Everard Home [124], Brodie 
[33], and others, both recommended and practised tunneling 
of the obstructing body by the catheter; but this remedy was 
finally abandoned as dangerous. Chopart [47] records that 



PLATE I. 




Tunneling the Prostate. A False Passage has been Made in the Dilated 
Prostatic Urethra. — (Cruveilhier .) 



Tunneling the Prostate. 3 

when Astruc, ten years before his death, which occurred in 1766, 
was attacked by retention of urine, his attendant, Lafaye, 
attempted to introduce a catheter, but met with an obstruction 
from a tumor in the neck of the bladder. He therefore per- 
forated this by a lance-shaped stylet introduced through the 
catheter, which was open at the end; and by this means suc- 
ceeded in forcing the catheter into the bladder and drawing 
off the urine. The catheter was retained fifteen days. This 
false passage through the obstructing body persisted, and a cath- 
eter was introduced by r it as occasion required through the 
remaining ten years of Astruc' s life; and the condition of the 
parts as described was finally confirmed by the post-mortem 
examination. Chopart [47] himself tried tunneling of the 
prostate several times, but with fatal results. Billroth's [22] 
experience was likewise disastrous in the only case in which 
he used forced catheterization. 

Systematic compression to maintain a patulous urethra was 
first proposed by Physick [193], of Philadelphia. His method 
consisted in the introduction of an elastic hollow tube through 
the compressed prostatic urethra, as a catheter, and then its dis- 
tention by fluid pressure. Some success attended this remedy; 
and it was repeated every two or three days, the pressure being 
applied for as long a time as the patient could endure, usually 
from five to fifteen minutes. Leroy d'Etiolles [145] and Mercier 
[159] also made use of compression, in an effort to reduce the 
size of the prostate, or at least to mould it in its growth. Their 
plan consisted in introducing a flexible catheter, and then plung- 
ing into it a straight stylet, which forcibly overcame the natural 
subpubic curve of the urethra. Special instruments were designed 
for this purpose; but the remedy was so extremely painful in its 
application that it met with little general favour. The contemp- 
orary English surgeons, moreover, contended, and apparently 
with an element of truth, that no more was thus accomplished 
than by passing an ordinary steel sound through the urethra 



4 History. 

until its curved extremity was wholly within the bladder, when 
its straight staff would tend to depress the internal orifice of the 
urethra to its normal position. But probably the best-known 
advocate of systematic compression was Mr. Reginald Har- 
rison [no], of London. This surgeon, in 1881, devised special 
olivary bougies, of gum elastic, from two to four inches longer 
in the stem than the ordinary instruments, and having an 
expanded portion an inch from the tip, which was made to 
enter the bladder. By this means the olivary swelling caused 
dilatation of the urethra and compression of the prostate both as 
the instrument was introduced into the bladder, and again as 
it was withdrawn, it being allowed to remain in place for several 
minutes. 

As is the case with every other department of surgery, opera- 
tive treatment was at first undertaken only in emergency cases, 
where retention of urine existed; or incidentally as part of 
another operation, such as lithotomy. 

Perineal operations came into favour earlier than those by 
the suprapubic route, owing probably to the greater familiarity 
of surgeons with operations in the former region, due to the 
then widespread practice of perineal lithotomy. Covillard [53] 
in 1639 successfully operated by perineal cystotomy, and removed 
a hard mass, not a stone, crushing and destroying it during ex- 
traction with the forceps. This was an isolated case, not under- 
taken for urinary retention, and does not represent the usual 
practice at that date. Sir Henry Thompson [224], in referring 
to this case, asserts that the "hard mass" was a true tumor 
of the bladder; but Gouley [100] seems to have considered it 
prostatic. 

Chopart [48] describes how Desault, who died in 1795, 
found and twisted off a tumor in the bladder, after removing a 
calculus by perineal lithotomy; and Sir William Blizzard [25] 
several times before 1806 performed perineal prostatotomy for 
enlargement without any calculous formation. It has been 



PLATE II. 



Harrison's Olivary Bougies. 



Mercier's Operation. 5 

denied by some writers that Sir William Blizzard's operations 
were anything more than the opening of prostatic abscesses; 
but he distinctly says that his object in performing such an 
operation was to reduce the size of the gland by incision, irre- 
spective of the presence of pus, which he says may have been 
absorbed, only induration remaining. (See Guthrie [107], 
p. 252.) 

Perineal prostatotomy combined with lithotomy was by no 
means unfrequent in the early part of the nineteenth century, 
and was sanctioned by Sir William Fergusson [78], who em- 
ployed this procedure before 1848. 

Amussat [6] removed a calculus and a protruding mass of 
the prostate by suprapubic cystotomy before 1832. 

But the first regular surgical procedure was established in 
1834 by Guthrie [107], under the name of " division of the bar 
at the neck of the bladder," this bar in some cases being pro- 
duced by a fold of mucous membrane stretched taut across the 
vesical orifice of the urethra by symmetrical enlargement of the 
two lateral lobes of the prostate. He accomplished his purpose 
by a catheter carrying a concealed blade. Where marked pros- 
tatic enlargement coexisted, he advised perineal prostatot- 
omy, but it is not certain that he ever performed it. Mercier 
[159], whose name is pre-eminent in the early days of prostatic 
surgery, devised in 1837 special instruments — called by Gouley 
[100] " prostatotome " and "prostatectome"— and at later 
dates modified them in various ways. These instruments were 
all used much as the internal urethrotome is used at the present 
day, without either a suprapubic or a perineal opening; and did 
not meet with very general favour. Leroy d'Etiolles [145] as well 
as Civiale [159] claimed priority over Mercier [159] in the inven- 
tion of instruments for the operation (urethral prostatotomy) 
since known by the latter' s name; but it appears that their claims 
are ill founded. Indeed, so occupied were they with one another's 
claims that they seem to have at times entirely overlooked the 
fact that Guthrie [107] was the originator of the method. 



6 History. 

A further improvement on Mercier's method was that intro- 
duced about 1873 by Bottini [27 and 28], then of Pavia, who aimed 
to avoid the haemorrhage attendant upon Mercier's operation by 
the use of a galvano-caustic incisor. Gouley [100], however, 
who had considerable personal experience with Mercier's method, 
which he nevertheless preferred to apply through an external 
urethrotomy wound, asserted that the bleeding was trifling, and 
that therefore Bottini' s modification was unnecessary. Although 
the Bottini operation was enthusiastically practised by its ori- 
ginator and a few other Italian surgeons during the twenty years 
or more following his first description of it, yet it by no means 
met with general favour until after the publication in 1897 of 
the well-known paper by Freudenberg [80], who introduced 
many improvements in the requisite apparatus. This surgeon 
four years later recommended the addition of a centimetre scale 
to the shaft of the Bottini cautery, in order that the operator 
might have a more definite idea of the position of the beak of 
the instrument when in use. Further modifications of the gal- 
vano-caustic apparatus have recently been introduced by Dr. 
H. H. Young [260], of the Johns Hopkins University, the 
greatest advantage being that the slipping away of the prostate 
from the beak of the instrument is rendered nearly impossible, 
and that thus the risk of burning through the bladder wall instead 
of through the hypertrophied gland is minimized. 

In America Dr. Willy Meyer [163 and 165], of New York, 
and Dr. Orville Horwitz [125], of Philadelphia, have been among 
the most prominent advocates of the Bottini method to the 
practical exclusion of all others. 

Belfield in 1886 advocated the employment of Bottini's method 
through a perineal wound. His advice has been reiterated by 
Watson (1888) [242], Keyes, Jr. (1902) [134], and Wishard 
(1902) [253]; while Watson (1888) [242], Bangs (1898) [12], 
and Bouffleur (1902) [31] also recommend the employment 
of a cautery through a suprapubic opening. 



PLATE III. 





Mercier's Prostatotome and Prostatectome. 



Puncture of the Bladder. 7 

Meanwhile various other methods of treatment had been 
introduced. Of these, the most important are those that arose 
from the practice of tapping the bladder in cases of retention 
of urine where passage of the catheter proved impossible. Simple 
catheterization to relieve the bladder of its residual urine had 
long been employed; Home [123] had even used continuous 
catheterization — for periods of from one to three months — for 
the relief of the cystitis. It is interesting to note that the clever 
manoeuvre of increasing the curve of the catheter by partially 
withdrawing the stylet as its beak approached the obstruction 
was practised and taught by Physick [193], the Father of Ameri- 
can Surgery, long before it was accidentally discovered by Mr. 
Hey. Dorsey figures in his "Surgery," published in 1818, a 
catheter with the well-known prostatic curve, which is in this 
case exaggerated, and, as Dorsey says, is probably as great as 
will be found necessary in any case of enlargement of the prostate. 
The instrument known as the " elbowed catheter" of Mercier, 
originally of silver, and devised by him as a modification of the 
stone searcher, is now usually made of webbing, and has been 
found most useful in gaining access to a bladder with prostatic 
obstruction by the facility with which its point rides over the 
projection at the vesical orifice of the urethra. 

Where it was found impossible to introduce the catheter, 
the bladder was punctured, either suprapubically or through 
the rectum. Perineal puncture, though practised during the 
seventeenth and eighteenth centuries, fell into disuse during the 
early part of the nineteenth, the rectal route being the favourite. 
Suprapubic cystotomy for urinary retention is an operation over 
three hundred years old, having been advocated by Rossetus 
[202] in 1590; but it was feared by most surgeons, in the early 
part of the nineteenth century, that in employing suprapubic 
puncture there would be great danger of urinary infiltration 
among the layers of the abdominal wall; and since it was found 
that in many instances, even after the cannula was withdrawn, 



8 History. 

the rectal puncture served fairly well for micturition until the 
urethra again became patulous through the subsidence of in- 
flammation, this was the operation usually adopted. Toward 
the middle of the last century some surgeons returned to the 
suprapubic route, while others considered a perineal puncture 
the only sensible treatment; and rectal puncture was cast aside 
almost wholly. 

From these various procedures arose finally a new method of 
treatment — that by urinary fistula; and from the concomitant 
drainage of the bladder it may be considered a distinct advance 
in therapeusis. Needless to say, some of the patients treated 
as above described, by puncture of the bladder for retention 
of urine, developed fistulous tracts which failed to heal. Thus 
Parrish [189] records that a patient whose bladder had been 
tapped suprapubically for prostatic retention by Dr. Wistar (who 
died in 1818) wore a gold tube in the fistula for two years; at 
the end of this time normal urination through the penis returned, 
and the tube was discarded, with the result that death soon fol- 
lowed from a recrudescence of the bladder troubles. This opera- 
tion had been done, like innumerable others, for prostatic reten- 
tion where the urethra was impassable; and Sir Henry Thomp- 
son [225] narrates that he saw some patients of Mr. Thomas 
Paget, who had had their bladders punctured suprapubically, 
completely relieved of the tenesmus and other distressing features 
by wearing a cannula or a catheter in the suprapubic fistula; and 
that this sight gave him encouragement to try the effect of per- 
manent drainage even in patients where retention of urine was 
not complete, and where the urethra was still open to instru- 
mentation. When a suitable case presented itself, he accordingly 
introduced through the urethra a long curved metal catheter, 
whose point was closed by a conical obturator (Plate iv); and, 
making this point impinge upon the wall of the bladder above 
the pubic symphysis, cut down upon it with a small incision. 
He then caused the catheter to protrude through the suprapubic 



PLATE IV. 




W 



Urinary Fistula. 9 

wound, withdrew the obturator, passed a cannula like a tracheot- 
omy tube into the point of the catheter, and by withdrawing 
this latter through the penile urethra, left the suprapubic tube 
in the bladder. Sir Henry Thompson's observations were first 
published in 1875, and in many cases in which he employed this 
method the relief afforded was marked, but he later abandoned 
this plan of treatment for drainage through the perineum. Dittel 
[69, 70], Keyes [131], and Swinford Edwards [75] were among 
the other surgeons who at one time or another recommended 
the suprapubic fistula. 

An important improvement in the method of forming the 
suprapubic fistula was that introduced in 1888 by Hunter 
McGuire [155]. He formed an artificial urethra in the hypo- 
gastric region by establishing a fistulous tract upward from the 
bladder, so that the fistula "bore the same relation to the bladder 
that the spout of a coffee pot does to the bowl." By this pro- 
cedure McGuire was able to completely relieve his patients 
of their cystitis and residual urine, no involuntary leakage 
occurring even in the supine position, and the patients in some 
instances being able to project the stream of urine in a parabolic 
curve to a distance of several feet by voluntary contraction of 
the bladder. The urine was retained for from two to six hours. 
Morris [171], of New York, in one instance clothed the fistulous 
tract with skin by transferring narrow cutaneous flaps into the 
wound at the time of operation. Poncet and Delore [194] have 
exhaustively studied the subject of suprapubic fistula as a means 
of treatment for patients with enlarged prostate; and the reader 
is referred to their work for further information. It is interesting 
to note that Delore [59] collected three cases where patients 
who had had urachal fistulas in childhood had these open again 
spontaneously when in old age they developed prostatic reten- 
tion. 

The treatment by perineal fistula developed as a natural con- 
sequence of puncture by the perineum, and from the practice 



io History. 

of perineal cystotomy for calculus complicated by enlarged pros- 
tate. Besides the mere cystotomy, it was customary to do a 
prostatotomy, and even a digital divulsion of the obstructing 
organ. The establishment of a perineal fistula with perineal 
prostatotomy was a method largely employed by Reginald Har- 
rison [in], commencing in 1881, his first operation having been 
performed on November 4th of that year. He used a small 
perineal incision, opening the membranous urethra; then the 
prostate was incised; and a metallic perineal tube introduced 
and retained for from six to twelve weeks. If the natural chan- 
nel was not eventually restored, the fistula persisted. Prof. 
Gouley [100], of New York, claimed priority over Harrison 
in the re-introduction of perineal prostatotomy, his first opera- 
tion — in which, however, he left no instrument in the bladder — 
having been performed April 27, 1880; and his third operation, 
in which he left a large-sized rubber tube in the perineal wound, 
having been done in January, 1881. Whitehead [249] and Braun 
[32] were likewise among the earlier advocates of the treatment 
by a more or less permanent perineal opening. 

Various other methods of treatment, supported by different 
surgeons, have, at one time or another, claimed the attention 
of the profession. Heine [119] recommended the injection of 
iodine into the prostate, and Langenbeck [143] and Iversen [129] 
the subcutaneous use of ergotine, in the hope of causing a reduc- 
tion in the size of the gland. The parenchymatous injections 
were given through the rectum, but in some cases treated by 
Heine's method (see Dittel [68]) it was found that suppura- 
tion and even death followed, so that this practice was never 
very generally employed. Electricity has been employed in 
these cases, and at times with a certain measure of success; 
although the cases so reported are open to the criticism of having 
possibly been merely those of chronic prostatitis, and not of true 
enlargement. This method has been carefully studied by 
Cheron and Moreau-Wolf [169], to whose excellent monograph 
the reader is referred. 



PLATE V, 




Suprapubic Prostatectomy. n 

Excision of the obstructing parts of the enlarged prostate 
by suprapubic cystotomy was first widely advocated by McGill 
[152], of Leeds, in 1887. Before this date he had prac- 
tised permanent suprapubic drainage, which he preferred to 
that by the perineum. Belfield [16], in America, had done 
suprapubic prostatectomy before this time, his first operation 
being in October, 1886; Dittel [71] had in 1885 removed 
a portion of an obstructing prostate through a previously existing 
suprapubic fistula, which he enlarged for the purpose ; Trendelen- 
burg [230], in May, 1886, and Benno Schmidt [208], in August 
of the same year, had employed this route for removal of 
pieces of the prostate; but to McGill has always rightly been 
attributed priority in bringing this procedure prominently before 
the profession. The most enthusiastic supporters of McGilPs 
operation have been Buckstone Brown [34], Kummel [140], 
Atkinson [11], Keyes [131], and Fuller [92]. 

As originally practised, this operation consisted in cutting 
off, through the usual incision of suprapubic cystotomy, by means 
of scissors, or of rongeur forceps (Keyes) [131], twisting off 
with bladder forceps, strangulating with an ecraseur (Tobin) 
[228], or crushing with a lithotrite, any projecting masses of 
prostatic tissue. It was, however, in time extended so that 
portions of tissue, forming the so-called prostatic tumors, were 
enucleated with the finger, either alone, or aided by the scissors 
or other instrument, from their position deep within the gland. 
There are not wanting, indeed, surgeons — among them Watson 
— who claim to have removed the entire prostate gland by a 
procedure strictly similar to that recently so ably advocated by 
Mr. P. J. Freyer [85 to 90]; but as they do not appear to have 
thought the profession in general worthy of their confidence 
until stimulated by the reports of Mr. Freyer, to that surgeon is 
undoubtedly due the credit of bringing (1901) before the medical 
world a plan of operation whereby an attempt is made to enu- 
cleate the whole organ. Through a suprapubic incision he opens 



12 History. 

the bladder, and incises, by a cut parallel to the urethra, the 
mucous membrane overlying each of the two lateral lobes of the 
affected gland. Then by working merely with the finger he 
states that he has been able to enucleate the entire prostate, 
leaving the urethra intact. 

Many other surgeons have laboured to prove that such an 
operation is not only surgically, but even anatomically impos- 
sible, assailing Mr. Freyer's claim to originality, and asserting 
that he is labouring under a grave misapprehension if he thinks 
he is the first person to operate in this manner; insisting that 
his method is nothing more than the removal of very large pros- 
tatic tumors from the substance of the gland, leaving behind 
the outer margin of glandular tissue which by the growth of these 
tumors has been compressed into a thin capsule-like layer. Thus 
Wallace [239] says: "The more rapidly growing areas (of the 
diseased prostate) increase at the expense of the more slowly 
growing ones, which are compressed and stretched over the 
surface of their quickly growing neighbours. By this process a 
capsule is formed, ill-defined at first, but later becoming more 
distinct. The elements forming this capsule show in process 
of time a lamellar disposition. The adenomatous mass can now 
be easily enucleated, and not only presents a smooth surface, 
but also leaves behind a smooth cavity." One "capsule" which 
he describes, left behind after the post-mortem removal of the 
prostate, showed within its layers a small lenticular focus of 
glandular tissue. He therefore concludes: "These facts . . . 
seem to leave no reasonable doubt that the so-called total 
prostatectomy is nothing more than the removal of adenomatous 
masses." Yet he admits that "if during life the urethra had 
been sacrificed, and the whole central mass removed, the operator 
would have been justified in believing that he had removed the 
entire organ; certainly nothing recognizable as prostate would 
have been left behind." Taylor [222] entirely concurs in the 
opinion above expressed by Wallace, to the effect that total 



Freyer's Operation. 13 

enucleation of the prostate gland is an impossible operation; 
but Roberts [201], as the result of a careful examination of the 
structures left after a post-mortem enucleation of the prostate 
gland by Freyer's method, is of the opinion that the whole gland 
can be removed during life, since in his experience just alluded 
to no trace of prostatic tissue could be found remaining behind. 
The studies of J. W. Thompson Walker [236 to 238] confirm the 
opinion of Roberts. 

It seems a pity that so many controversies in regard to surgical 
priority are so constantly arising, and it appears that prostatic 
surgery is particularly unfortunate in this respect. Riolanus 
[200] bitterly denounced his contemporaries for claiming as 
their own operations which had been employed before their 
grandfathers were born, and for a hundred years before even 
that time. Mercier [159] asserted that Civiale and Leroy d'Et- 
iolles had assumed the credit of operations which were not their 
own, and, with that delightful tendency toward the argumentum 
ad hominem characteristic of the French nationality, added 
that Leroy had also assumed a name to which he had no right, 
since in reality Leroy was from Paris, not from Etiolles. Gouley 
[100] spoke almost venomously against Mr. Harrison; and I 
think Mr. Freyer would be well able to respond to his critics 
as Harrison [115] did to Prof. Gouley: "I see that Dr. Gouley 
claims priority for the proceeding just described; what is of 
more importance is that it has received his approval." 

Whether or not every shred of prostatic substance is removed 
by Freyer's operation is of very little consequence; who first 
performed such an operation is of less; and whether it is ana- 
tomically possible or not is of no consequence at all; since the 
results in Mr. Freyer's cases speak for themselves, and he has 
aroused the profession, not only in his own country but in France 
and America as well, to the realization of what a brilliant chapter 
of prostatic surgery is unrolled in his achievements. Indeed, 
were I inclined to criticize the reports of Mr. Freyer's cases in 



14 History. 

any way, it would be to say that they were almost too good to 
be believed, except when coming from such a source, so much 
like a fairy story do they read. 

Freyer's operation has been ably illustrated by Moynihan 
[178] and by Barling [13]. 

Prostatectomy by the perineal route followed close on the 
practice of perineal prostatotomy, and preceded by a number 
of years Mc Gill's introduction of the suprapubic method. Em- 
ployed first for malignant disease (by Kuchler [139] in 1866, by 
Billroth [21] in 1867, by Demarquay [61] in 1873, by Langen- 
beck [143] in 1876, by Spanton [213] in 1882, and by Leis- 
rink [144] in 1883), its field of application was soon broadened 
so as to include benign enlargement. At first, as in the parallel 
case of the suprapubic operation, portions only of the prostate 
were removed, but within the past ten years the technique has so 
much improved that total prostatectomy by the perineal route 
is even more widespread than that by the suprapubic method. 
Many prominent surgeons have advocated the perineal route, 
including Harrison (1881), Ashhurst (1882), Annandale (1888), 
Zuckerkandl (1889), Watson (1889), Dittel (1890), Goodfellow 
(1891), H. Morris (1895), Ferguson (1901), Syms (1901), Albar- 
ran (1901), Petit (1902), Moore (1902), Murphy (1902), Bryson 
(1902), Young (1903), Senn (1903), and Proust (1903). 

The simplest perineal operation is done through a straight 
median incision. It is that which I have myself employed, and 
which was almost universally used until within the last few years. 
Goodfellow [98] is among the few surgeons who employ it 
still; and through it he has removed the entire prostate, much 
as Mr. Freyer does through a suprapubic opening, since 1891, 
being a pioneer in this field. To gain more room some sur- 
geons have supplemented the median incision by an oblique cut 
on each side of the anus, making an inverted Y-shaped incision ; 
this method has been advocated by Murphy [181], Baudet 
[14], and Senn [209]; while Zuckerkandl [263] advises a 



Perineal Prostatectomy. 15 

transverse semicircular incision, making a flap toward the rec- 
tal aspect, this tube being separated from the anterior structures 
by blunt dissection. A similar though less extensive skin flap is 
employed by Albarran [2], Proust [196], and other French sur- 
geons, as well as by Young [260], who closely follows their 
technique. Dittel [72] aims to get still more room by an in- 
cision completely encircling the right side of the anus from 
the coccyx, and continued forward in the median line of the 
perineum; by this approach he is enabled to remove a wedge- 
shaped piece of each lateral lobe. The coccyx may be excised 
if more room is required for completing the operation. 

The position used for these variously modified operations 
differs somewhat: thus, although the usual lithotomy position 
suffices for most surgeons, many prefer to have this much exag- 
gerated, while Proust [196] mounts his patients on a sort of frame- 
work, so that the perineum is completely inverted. Dittel [72] 
employs either the right lateral decubitus, or else has the patient 
placed on the table in the prone position, with the thighs hanging 
vertically downward. 

These perineal operations all differ much in some minor 
details of technique, as to whether the urethra is opened or not, 
whether an attempt is made to preserve the ejacuiatory ducts, 
and as to the special instruments employed; some of these 
matters will be discussed in the last chapters of this book; but 
for such as appear of purely historical interest the reader must 
consult the original articles referred to in the appended biblio- 
graphy. 

Combined operations, by the perineal amd suprapubic routes, 
have found a number of supporters. Nicoll (1895) [183] removed 
the gland through the perineum, aiding its extraction by pushing 
the prostate down by the fingers of one hand introduced into 
the bladder through a suprapubic wound. Alexander (1896) 
[4] removed it through a suprapubic cystotomy by the aid of 
the fingers of the other hand in a perineal wound. Bryson (1899) 



16 History. 

[36] and Guiteras (1901) [106] have employed a perineal 
operation in which counterpressure is afforded by the fingers 
introduced through a suprapubic incision only into the space 
of Retzius; while another enthusiastic surgeon (Syms) [220], 
thinking the extraperitoneal opening of an infected bladder too 
dangerous an operation, has proposed freely opening the peri- 
toneal cavity and conducting the manipulations for counter- 
pressure through the unopened bladder-walls, while the prostate 
is extracted through the perineum. Fuller (1895) [92] did a 
suprapubic prostatectomy, and then drained by means of a peri- 
neal cystotomy, completely closing the suprapubic wound on 
the removal of its drainage on the fourth day. 

Other operators have devised special instruments by which 
to draw the prostate down into the perineal wound without 
making any suprapubic opening. Murphy [181] employs hooked 
retractors which grasp the gland from its lower surface; and 
Syms [220] uses a special hollow rubber retractor, introduced 
into the bladder through a perineal incision in the membranous 
urethra, the instrument being kept in place by distending its 
bulbous extremity with water. Proust [196] and Young [261] 
each employ a special prostatic tractor; but most surgeons have 
found it sufficient to use an ordinary steel sound, or stone- 
searcher, introduced through either the penile urethra or a 
perineal urethrotomy wound, making traction by inverting the 
curved end over the enlarged prostate. 

A mode of treatment by castration, advocated in 1893 by 
J. William White [247], though widely employed by some 
surgeons for several years, is no longer in favour. White sug- 
gested this method in June, 1893; in September of the same 
year Ramm [197], of Christiania, published the results of cas- 
tration on two patients, on whom he had operated the preceding 
April. Boeckmann [26] had done a similar operation in May, 
1893, and it appears that Tupper [231], on two occasions, in 
1882 and 1886, had performed this operation with the deliberate 



Castration. 17 

intention of relieving prostatic troubles, after having seen the 
effect produced by the removal of the remaining testicle from 
a patient whose first testicle had been removed for other causes. 
Ssnitzin [214] had employed this operation in 1886. Launois, 
according to Moullin [176], suggested this form of treatment to 
Guyon in 1884; and Mr. Moullin himself discussed its advisa- 
bility with a patient in 1892. 

All of these observations were much antedated by those of 
John Hunter [128], who, in experimenting on animals, had shown 
that double castration in young animals prevented the develope- 
ment of the prostate, and that in adult animals it caused the 
fully developed gland to atrophy and waste away. It had, 
moreover, been known for many years that in certain animals, 
such as the mole, which have stated periods for sexual inter- 
course, the prostate is much diminished in size during the inter- 
vals, and hence it was inferred that a continuous abeyance of 
the sexual function would cause atrophy of the prostate in men. 
Vasectomy was suggested by Mears [158] as a less severe and 
mutilating operation, and seems likely to continue in use for 
certain cases for a longer time. The mortality from castration 
for enlarged prostate is at least 18 per cent. (White) [248], 
taking all cases together; and in selected cases has been reduced 
only to about 8 per cent. (Wood) [257]. Griffiths [105] and 
Mansell Moullin [175] have been its chief advocates in Great 
Britain. 

Ligation of both internal iliac arteries to induce ischaemic 
atrophy of the prostate was proposed in 1893 by Bier [19], and 
employed by him in three cases, one of the patients, operated 
on intraperitoneally, dying from septic peritonitis. Of eight 
patients subsequently operated on intraperitoneally by Bier, 
two died. Willy Meyer [160, 161] practised this operation in 
three cases, the first patient recovering, after secondary haemor- 
rhage and partial gangrene of the left foot; but the second died, 
apparently of renal disease, eight days after the operation; while 
3P 



18 History and Literature. 

the third was in nowise benefited by his experience. Konig 
[136] also reported one patient, operated on by another sur- 
geon, in Chicago, no change in the urinary condition being 
produced. Of those patients who survived (eleven out of fifteen), 
eight are said to have had their bladder troubles more or less 
relieved, while three received no benefit whatever, and four died, 
a mortality rate of over 26 per cent. Derjuschinsky [63, 64] 
investigated this method of treatment by conducting experiments 
upon dogs, and demonstrated that although primary decrease 
of size of the prostate occurred, yet that at about the end of 
eight months' time it had regained its original volume by virtue 
of the establishment of the collateral circulation. I do not wish to 
be understood as countenancing this method in any way, and 
mention it merely as a matter of historical interest. 

Among the more important monographs which have appeared 
at various times, treating of diseases of the prostate gland, men- 
tion should be made of those by Sir Everard Home (181 1), Leroy 
d'Etiolles (1840), Coulson (1840), Adams (185 1), Hodgson (1856), 
Thompson (1858), Gant (1872), Harrison (1884), Guyon (1888), 
Rouchaud (1888), Watson (1888), Vignard (1890), Moullin 
(1894), Poncet and Delore (1899), Freyer (1901), Petit (1902), 
Socin and Burckhardt (1902), and Proust (1903). Of these, 
I desire to express my special indebtedness to those by Hodgson, 
Thompson, Moullin, Socin and Burckhardt, and Proust. To 
the encyclopaedic character of the monograph of Socin and Burck- 
hardt, the bibliography of which contains over two thousand 
references, I am under great obligations. Besides these mono- 
graphs, innumerable shorter articles have been published, to 
enumerate even a small part of which would be utterly imprac- 
ticable in a book of this kind. In the bibliography which is 
appended to this work will be found references only to those 
authors who have been quoted by name in its pages, or who have 
been consulted in its preparation. The original has been con- 
sulted in every case in which it was accessible, and where it has 



History and Literature. 19 

not been, pains have been taken to indicate the medium of in- 
formation. It is hoped that the list may prove of service to 
those students of the subject who wish to refer to its literature 
in greater detail. 



CHAPTER II. 

EMBRYOLOGY; COMPARATIVE ANATOMY; GROSS AND 
MICROSCOPICAL ANATOMY ; RELATIONAL OR APPLIED 
ANATOMY; AND PHYSIOLOGY. 

Embryology. — Although the ovary and testicle can be dis- 
tinguished microscopically about the ninth week, the prostate 
gland is not recognizable until the third month of intrauterine 
life. It will be convenient, therefore, to briefly review the de- 
velopement of the genito-urinary organs from this date. 

It will be>recalled that the genito-urinary tract is developed 
from three main sources — the Wolffian bodies and ducts, the 
Mullerian ducts, and the allantois. This last structure, which 
is the earliest of the three to be formed, juts forth in the second 
week from the primitive gut near its posterior extremity, devel- 
opes forwards and protrudes at the umbilicus, forming a reservoir 
for waste materials. In the third week the Wolffian bodies 
appear, one on each side of the body cavity, as a series of tubules, 
caudal to the region of the heart, and lying approximately at 
right angles to the Wolffian ducts, and in the long axis of the body 
cavity. The Mullerian ducts, one on each side, appear about 
the fifth week, and lie parallel to the Wolffian ducts. Both 
pairs of ducts empty into the portion of the allantois closest to 
the gut. In the sixth week one can see that the allantois has ex- 
panded slightly between its point of departure from the body 
cavity at the umbilicus, and the point at which it receives the 
two pairs of ducts — Wolffian and Mullerian. This expanded 
part of the allantoic tube forms the future urinary bladder; 
and growing out from it, practically parallel with the two pairs 



PLATE VI 




Developement of the Genitourinary Tract (Diagrammatic). 



Ellll Body wall. A. Allantoic stalk at umbilicus. B. Urinary bladder. C. 
Cloaca. G. Primitive gut. 5. Symphysis pubis. M, M' . Miillerian ducts. 
W, W. Wolffian bodies and ducts. U, U' . Ureters with kidneys attached. 



Embryology. 21 

of ducts, is now observed a third pair of tubes, these being the 
ureters. The altered portion of the allantois into which the 
Mullerian and Wolffian ducts empty is known as the urogenital 
sinus. That portion of the allantois between the urogenital 
sinus and the bladder later constitutes the urethra, as seen in 
the female. In the male this original urethra becomes sub- 
sequently greatly lengthened by the developement of the penile 
portion by an infolding of the skin along the lower border of 
the penis. 

As is well known, the Wolffian ducts persist in the male and 
form the vasa deferentia; while in the female the Mullerian 
ducts persist, coalescing in their lower portions to form the uterus 
and vagina, but in the upper part remaining distinct, and con- 
stituting the Fallopian tubes. In the male, although these Mul- 
lerian ducts in great part disappear, yet their lower coalesced 
extremity persists, and is found in the adult as a little diverti- 
culum from the prostatic urethra, known as the uterus mas- 
culinus. 

As mentioned above, the prostate gland is first discoverable 
in the third month of foetal life, and it can then be recognized 
as a thickening of the posterior wall of the urethra. Thus the 
analogue of the prostate gland must be sought in the female, 
not around the uterus, but, as Sir James Y. Simpson [211] says, 
"in the follicular glands and structures that exist so abundantly 
in the course, and at the extremity, of the female urethra"; and 
Hodgson [122] quotes Leuckhart as stating that in women there 
exists a true rudimentary prostate, consisting principally of 
mucous follicles and situated between the beginning of the urethra 
and the reflection of the vagina. He further states that Virchow 
admitted the existence of this body, and had often found at the 
neck of the bladder, especially in old women, when the internal 
orifice is thickened, round grayish-yellow enlargements in which 
there are gradually formed firm dark-coloured bodies lying em- 
bedded in the mucous membrane. These bodies Virchow con- 



22 Anatomy. 

sidered identical with or analogous to the concretions found 
in the prostatic portion of the urethra. Guthrie [107], writing 
in 1834, had no doubt that females possessed a prostate. 

Most observers have held that while the glandular portion 
of the prostate originates thus from the urethra, yet that the 
stroma of the organ developes from a thickening of the genital 
chord — which is the name given to the connective tissue containing 
the Wolffian and Mullerian ducts. But Griffiths [103, 104], 
who studied the developement of the prostate in considerable 
detail, taught that no part of the prostate arose from the genital 
chord. W. G. Richardson [199] from his more recent studies 
is of the same opinion. Griffiths [104] described the course 
of events as follows: The normal tubular glands of the ure- 
thra on its posterior surface, especially on each side of the 
verumontanum, grow outward, backward, and finally turn and 
come forward, so as to enclose the sides of the urethra, and at 
last coalesce again on its anterior (superior) surface. During 
their growth these glands project into and between the muscular 
fasciculi of the thickened posterior half of the external circular 
non-striped muscle coat of the urethra in this situation. This 
external circular layer of muscle is the continuation of the cir- 
cular coat of the bladder, the bladder's external muscle-coat, 
which is longitudinal, ceasing at and being inserted at or near 
the vesical orifice of the urethra. 

Naturally, therefore, we find that in the adult the prostate 
surrounds the uterus masculinus, being anatomically merely a 
compound tubular developement of the urethral glands on the 
two sides of this rudimentary structure. (Compare the genitalia 
of the goat, Plate rx.) 

As the foetus continues to develope it is found that the Wolf- 
fian ducts (vasa deferentia) empty into the urethra upon or 
even within the margins of the coalesced Mullerian ducts (uterus 
masculinus) ; while the orifices of the prostatic (highly developed 
urethral) glands retain their original situation on each side of 



PLATE VII, 




Fcetal Prostate, with Lower Halt of Bladder Attached. 
Natural size, and ten times natural size. (From a six months' foetus in the Museum of 

the German Hospital.) 



Embryology. 23 

the opening of the uterus masculinus. Thus is explained the 
apparent passage through the prostate of the ejaculatory ducts 
of the vasa deferentia. 

The two lobes remain distinct until about the fifth month of 
intrauterine life, when they coalesce about the urethra. Even 
at birth the prostate can be recognized as a bilobed organ, lying 
almost entirely behind the urethra. In rare instances the urethra 
has been found in the adult to merely groove the anterior surface 
of the prostate, and not to be completely encircled by it, as is 
usually the case. 

In connection with the embryology of the prostate a few 
words must be said in reference to the so-called " third lobe." 

From the account of its developement just given it is seen that 
the prostate is really a paired organ, arising in two distinct places 
from the urogenital sinus, much as the ureters do from the blad- 
der; and when the gross anatomy of the organ is studied it will 
be seen that the bilobed condition persists with more or less dis- 
tinctness throughout life. From the day of its discovery the 
prostate was constantly referred to as the "glandulae prostata? " 
— the " prostate glands," showing that it was considered as a 
multiple organ, composed of numerous glands; and its bilobed 
state in fcetal life was well known. It was not until about one hun- 
dred years ago that Sir Everard Home [123] took credit to him- 
self for discovering a third lobe, although both John Hunter [128] 
and Morgagni [166, 167] had recognized a pathological enlarge- 
ment of this part of the organ a number of years before. Home's 
observations passed practically unchallenged .among English 
surgeons, and enlargement of the third lobe became the most 
popular pathological change to which the prostate gland was 
subject. In France, however, surgeons were not so ready 
to acknowledge so important a discovery, as it seemed, by a foreign 
author; and they rather grudgingly denominated this portion 
of the prostate the third or median "part," being unwilling to 
accord it the dignity of a distinct lobe. 



24 Anatomy. 

Sir Henry Thompson [224], writing in 1858, opened the con- 
troversy anew by pointing out both that Home's observations 
were not numerous, and that he had not found his third lobe in 
every case. Sir Henry therefore came to the conclusion that 
this middle lobe was merely a pathological formation, and did 
not normally exist at all. Griffiths [103] in his studies, 
observed in the greater proportion of specimens examined by 
him, that posterior to the verumontanum, as well as on its two 
lateral aspects, orifices of gland ducts could be seen,* and that 
pressure on the corresponding portion of the gland squeezed out 
prostatic secretion from glandular tissue which he found lay 
between the urethra and the ejaculatory ducts. His conclusion 
was that a third or median lobe sometimes existed, but that it 
was not constant; and that where it was congenitally absent, 
it could, of course, never become the seat of enlargement. 

Such a collection of gland tubes might well be called an 
accessory lobe. Thorel [226] has described such accessory pro- 
static glands in the human subject, lying between the ureters, in 
the submucous tissue of the bladder; some such accessory glands 
are believed to exist in some of the lower animals; and since 
in the immense majority of cases, if not in all those carefully 
examined in recent years, a median projection has been found 
to take its origin by a pedicle from one or the other of the two 
lateral lobes, it is probably safe to conclude that a median or 
third lobe does not normally exist. There is, moreover, nothing 
to prevent us from thinking, in the cases described by Home and 
by Griffiths, that the glandular structure they found posterior 
to the urethra and above the ejaculatory ducts was as much 
separated into two lobes as that beneath the urethra and on 
both sides of, or anterior to, the ejaculatory ducts. 

A further embryological fact of importance is the formation 
of a bursa between the prostate and the rectum, by the oblitera- 

*This position of the ducts from the third lobe was distinctly described by Home 
1 1 23], with whose original paper Dr. Griffiths does not appear to have been familiar. 



PLATE VIII. 




*mmamm 



Comparative Anatomy. 25 

tion of the upper end of a serous process extending downward 
from the peritoneum, much as the tunica vaginalis testis is formed. 
This closed serous cavity between the prostate and the rectum 
has been recently studied by Cuneo and Veau [55], and is 
widely known by the name " aponeurosis of Denonvilliers." In 
the adult, though separable into two layers, these processes of 
serous tissue no longer enclose a distinct cavity. 

Comparative Anatomy. — All mammals possess a prostate, 
but there is in birds, according to Strieker [218], no analogous 
organ. In certain of the batrachians he states that the pelvic 
and anal glands swell up during the procreative season, and 
discharge their secretion into the cloaca; these glands are sup- 
posed to represent the prostate and glands of Cowper. In fishes 
there are aggregations of acini that communicate with the vas 
deferens through ducts. Owen [184] states that insects have 
three pairs of prostates. 

Although all mammals are endowed with a prostate, yet it 
is by no means identical in form in all. In some mammals the 
prostate developes around the lower extremity of the Wolffian 
ducts, and when fully developed retains its close relation to the 
vasa deferentia, but as two distinct glands, and is not, as in the 
human adult, applied around the first portion of the urethra 
embracing the ejaculatory ducts only incidentally. Moullin 
[176] states that even in man the situation of the prostate was 
probably originally around the Wolffian ducts, but that its 
place has become shifted in the course of racial developement. 
In the bull, the buck, and other of the ruminants, indeed in almost 
all the forms of mammalian life below the human, including the 
monkey, the prostate continues throughout life a bifid gland. 
The close resemblance whichat bears in some of these animals 
to the seminal vesicles may account both for the ignorance of 
the ancients respecting the existence of the human prostate 
gland, and for the habit of the earliest of the modern anatomists 
of referring to it as the "glandulae prostatas" 



26 Anatomy. 

W. G. Richardson [199, p. 35] has recently called attention 
to the location of the accessory glands of generation — the pros- 
tates, the seminal vesicles, and the Cowperian glands — in various 
animals. He finds that the seminal vesicles are constantly in 
relation with that part of the genital tract developed from the 
Wolffian ducts, that the prostates are placed next, in relation 
with that part developed from the urogenital sinus, while the 
glands of Cowper are furthest away from the testicles, in rela- 
tion with the bulbous urethra. This same general arrangement 
exists in the human being, the glands of Cowper discharging 
their secretion into the bulbous urethra, the prostate glands into 
the prostatic urethra, and the seminal vesicles pouring their 
secretion into the vasa deferentia before these latter have joined 
the urethra. In the lower animals the accessory genital glands 
differ much in relative size and importance, all three sets not 
always being present. In the civet cat, for example, Cowper's 
glands are exceptionally large, apparently to compensate for the 
entire absence of the seminal vesicles; while in the guinea-pig 
the seminal vesicles are of immense size, and the glands of Cow- 
per very insignificant in comparison. In the squirrel, on the 
other hand, the Cowperian glands are very large, and the seminal 
vesicles are small. 

The genitalia of the goat (Plate ix) approach most nearly 
to the primitive or indifferent sexual type. Here the Miillerian 
ducts persist throughout their length, as well as the Wolffian 
ducts, and we have the unusual sight of the uterus masculinus 
extending as a bifid organ from the urethra to the epididymis. 
Nor do the lower ends of these persistent Miillerian ducts pierce 
the prostate to empty into the urethra; on the contrary, the 
prostate glands, one on each side of the urinary channel, are 
far removed from the situation of the uterus masculinus, being 
much nearer the bulbous urethra. This satisfactorily disproves 
the theory formerly held by some that the male prostate gland 
was the homologue of the female womb. 



PLATE IX, 




Testes, Prostates and Protometra of the Goat. 
Below are seen the prostates. Between the vasa deferentia is seen the uterus mas- 
culinus, which is bifid; its two horns diverge and continue, closely applied to the vasa 
deferentia, as far as the epididymis of each side.— {After Owen.) 



PLATE X. 




Accessory Male Glands and Protometra of Hyaena Striata. 
Above is seen the bladder. Emptying into the prostatic urethra are the vasa de- 
ferentia on each side of the minute uterus masculinus (protometra). The prostate glands 
are large, somewhat kidney-shaped bodies, in no way connected with the uterus mascu- 
linus. Emptying into the penile urethra below are seen the immense glands of Cowper. 
Natural size. — (After Owen.) 



Comparative Anatomy. 27 

In the hyena the genitalia (Plate x) approach more nearly 
the human in type, but conclusively show that there is no neces- 
sary connection between the uterus masculinus and the prostate. 
The Cowperian glands of the hyena are of extraordinary size. 

In mammals who have a rutting season the prostate gland 
enlarges noticeably at this period, and at its close again diminishes 
to its former size. John Hunter [128] studied the prostate gland 
in moles, and found that while it was small and insignificant 
during winter — the period of quiescence — yet that in the rutting 
season it became very large and was filled with mucus. His 
observations have been confirmed by Owen [185] and by 
Griffiths [104]. The last-named author also studied the pros- 
tates of hedgehogs, and found them to have the same charac- 
teristics. 

Such observations as these, taken together with the facts 
that castration in animals has long been known to produce a 
certain amount of prostatic atrophy; that failure of develope- 
ment of one vas deferens has usually been found associated with 
a prostate which is small and ill-formed on the affected side 
(see Plate xi); and the theory of "displacement" in the course 
of racial developement, adopted by Mr. Mansell Moullin [176] 
on the authority of Schafer; leave no reasonable doubt that 
the prostate is physiologically a part of the genital and not of 
the urinary apparatus. 

This idea may be further strengthened by a consideration 
of the ornithorhyncus, or duck-mole. In this animal, a small 
oviparous mammal of Australia, the urine is discharged through 
the cloaca, in common with the faecal matters, as is the case in 
birds; and the penis with its contained urethra serves solely 
and entirely for the transmission of the semen and the fluids 
from the accessory generative glands. And although, unfor- 
tunately for the complete proof of our theory, this interesting 
animal is not endowed with a prostate, yet it is clear that were a 
prostate present, its secretion would be discharged along with 



28 Anatomy. 

that coming from Cowper's glands, which, as well as the lower 
ends of the vasa deferentia, are considerably enlarged. No 
seminal vesicles are present either, but the enlargement of the 
lower ends of the vasa deferentia is evidently to compensate for 
this lack. 

In connection with the comparative anatomy of the prostate, 
a few words in relation to its comparative pathology will not be 
out of place. 

It is well known that of all animals the dog is most prone 
to prostatic enlargement. According to Ciechanowski [50], it 
is also the only domestic animal which suffers from an infec- 
tious urethritis. From this fact he draws an argument in favour 
of his theory that all prostatic overgrowth is due to an inflam- 
matory change. 

In other animals castration invariably causes prostatic 
atrophy; whereas in dogs it frequently fails to have any effect, 
although it was until recently about the only method of treatment 
applicable for their relief. Perineal prostatectomy has also been 
employed; and Loumeau [146] states that a veterinary surgeon, 
a friend of his, had employed ten times successfully an operation 
precisely similar to Freyer's suprapubic prostatectomy, before 
learning from Loumeau that the same operation had been prac- 
tised upon man. 

Gross Anatomy. — The shape of the prostate is approxi- 
mately that of a truncated cone, and has often been compared 
to a Spanish chestnut or a horse-chestnut, having its apex down 
and forward, and its base beneath the urinary bladder. In size 
this gland is normally about one and a half inches (four centi- 
metres) from base to apex, a little longer in transverse diameter, 
and from three-fourths to one inch (two to two and a half centi- 
metres) in depth or height. Its weight varies from four to six 
drachms (fifteen to twenty-four grammes). 

The prostate consists of glandular acini and ducts embedded 
in involuntary muscle; the latter, supported by fibrous tissue, 



PLATE XI. 




Congenital Absence of the Left Vas Deferens and Seminal Vesicle, Associated 
with Imperfect Developement of the Prostate on the Side Affected. — 
(Socin, after Lannois.) 



PLATE XII. 




Median Sagittal Section of the Lower Abdomen and Pelvis, showing the Gen- 
eral Relations of the Prostate to the Bladder, the Urethra, and the 
Rectum. 



Gross Anatomy. 29 

constituting the stroma of the organ. This stroma forms by a 
peripheral condensation a capsule for the gland, which is distinct 
from its sheath, this latter being derived from the pelvic fascia. 
The stroma constitutes more than half of the bulk of the organ, 
the remaining portion being composed of glandular tissue. 

Piercing the prostate from base to apex, a little anterior to 
its central axis, runs the urethra, whose first part, extending from 
the vesical orifice behind to the deep layer of the triangular liga- 
ment in front, is called "the prostatic urethra." 

Emptying into the floor of the prostatic urethra, and conse- 
quently coursing through the posterior portion of the prostate 
gland, are found the ejaculatory ducts of the vasa deferentia 
and seminal vesicles. One of these ducts empties on each side 
of a small diverticulum, known as the uterus masculinus, extend- 
ing backward from the floor of the prostatic urethra into the 
substance of the prostate gland. At times the ejaculatory ducts 
empty within the margins of the uterus masculinus. 

The uterus masculinus has its axis obliquely directed to that 
of the prostatic urethra, though lying in the middle line, and its 
cavity looks forward, so that a small catheter or sound passed 
along the floor of the urethra may catch in its orifice. The 
upper wall of the uterus masculinus causes, just back of its orifice, 
a prominence in the floor of the prostatic urethra; and this 
prominence is termed the caput gallinaginis or verumontanum. 
A transverse section, therefore, about the middle of the pro- 
static urethra is crescent-shaped, with the convexity upward. 
On each side of the caput gallinaginis are found the orifices of 
the ducts coming from the prostatic acini. Those depressed 
portions of the urethra on each side of the caput gallinaginis, 
into which these ducts empty, are known as the prostatic sinuses. 
The ducts may readily be demonstrated by compressing the 
gland, when some of the contained fluid will be seen oozing out 
from these orifices. The number of prostatic ducts probably 
varies within wide limits, being usually from fifteen to twenty. 



30 Anatomy. 

Any glandular tissue which may exist anterior to the urethra 
empties through ducts in the lateral walls of the urethra; and 
where glandular acini exist in that portion of the organ popularly 
known as the middle lobe (above the ejaculatory ducts, and 
below the urethra), their ducts discharge their contents into the 
floor of the prostatic urethra just posterior to the caput gal- 
linaginis. 

The prostate gland is formed by the coalescence of two lobes 
around the urethra. The lobes grow from behind forwards, and 
accordingly the exact depth in the gland at which the urethra is 
found depends somewhat upon the extent of the growth. In 
some instances the urethra has been found merely grooving the 
anterior or upper surface of the prostate; but in the majority 
of cases it is situated with one-third of the organ in front and 
two-thirds back of it. The developement as a paired organ is 
evidenced in the healthy adult gland by a slight longitudinal 
furrow along both the inferior and superior surfaces of the 
gland. On the inferior surface there is also a transverse cleft, 
serving for the passage forward to the urethra of the ejaculatory 
ducts. The inferior surface is rather flat, and rests upon the 
rectum. The superior surface is more convex, and is placed 
about three-fourths of an inch or less behind the lower part of 
the symphysis pubis. The base rests against the neck of the 
bladder, and the apex is in contact with the deep layer of the 
triangular ligament of the perineum. The axis of the prostate 
makes an angle of about forty-five degrees with the horizon, when 
the individual is in the erect posture. 

Sheath of the Prostate. — Tracing the transversalis or pelvic 
fascia down along the sides of the pelvis, we come to the white 
line of origin of the levator ani muscle, which stretches from the 
neighbourhood of the pubic symphysis in front to the spine of 
the ischium behind. At this white line the pelvic fascia divides 
into two sheets, the inferior or external (called the obturator 
fascia), passing between the obturator internus and the levator 



PLATE XIII 



Ejaculatory duct 
Rectovesical fascia 
Otturatorint 
ft/Mcbonc 



Bladder 

Prostate 

/tectum, 

levatorAni 




Ischium 1 

Gluteus maxima? \ 
Obturator fascia — * 
Int. Pud ic vessels & nerve 



m 

Analfasaa 

schio -rectal fossa 

jEzL Sphincter Ani 

Int. Sphincter Ani 



Transverse Section of Pelvis, showing the General Relations of the Prostate 

to the Pelvic Walls. Looking Forward Towards the Symphysis Pubis. 
The plane of section is nearlv horizontal with the subject in the erect posture. Compare 

Plate XVI. 



Prostatic Sheath. 31 

ani, and later giving off two processes — one, on the outer 
wall of the ischiorectal fossa, encircling the internal pudic vessels 
and nerve; while the inner layer covers the inferior or external 
surface of the levator ani, and is called the anal fascia. The 
second original division of the pelvic fascia, called the recto- 
vesical fascia, arising at the white line, passes over the superior 
or internal surface of the levator ani muscle, and subdivides into 
three layers: (1) The superior layer passes along toward the 
median line, above the prostatic plexus of veins, and over the 
upper surface of the prostate, and coalesces with the external coat 
of the bladder. (2) The middle layer of the recto-vesical fascia 
passes below the prostatic plexus of veins, beneath the prostate 
and bladder, and above the rectum, and joins with its fellow 
of the opposite side. (3) The third and last layer of the recto- 
vesical fascia hugs the superior or internal surface of the levator 
ani, and blends with the outer coat of the rectum. The two 
layers last described form together the aponeurosis of Denon- 
villiers [62], which lies between the prostate above and the rectum 
below, and is really a serous sac originally derived from the peri- 
toneum (see page 25), although more conveniently described 
here as part of the recto-vesical fascia. 

These three layers of the recto-vesical fascia are distinguish- 
able only at the sides of and below the prostate. Toward the 
median line above they are not separate, but form the pubo- 
prostatic ligaments, intervening between the most anterior fibres 
of the levator ani muscle (levator prostatas of Santorini [204]) and 
the space of Retzius, and blending at the median line, between these 
muscular fibres (where they contain the dorsal vein of the penis), 
with the fascia on the outer side of these muscles — the deep layer 
of the triangular ligament of the perineum, which is itself a pro- 
longation of the obturator fascia. 

Between this sheath of the prostate and its capsule various 
fibrous prolongations pass, surrounding the venous plexus in a 
mesh, and binding the prostate in place. Above the prostate 



3 2 Anatomy. 

these fibrous prolongations form a more or less firm septum, 
separating the pericapsular space around one lateral lobe from 
that about the other, and serving as well as a medium of sup- 
port. In cases of long-standing prostatitis and periprostatitis 
the strength of these fibrous partitions extending among the ven- 
ous plexus becomes much increased, and great force may be 
necessary to tear the prostate out of its enveloping sheath. 

Thus it is seen that the prostate is enclosed more or less con- 
centrically first in its own capsule ; then within its venous plexus 
at the sides and anteriorly, and by the bladder above; and, 
finally, outside of the venous plexus again, passes the sheath 
of the prostate. 

The Prostatic Plexus. — The dorsal vein of the penis passes 
beneath the subpubic ligament, being provided just before its 
passage with valves, sometimes three in number; and then 
divides into two branches which clothe the sides of the prostate. 
Here it is joined by veins from the substance of the prostate, 
and by other minor tributaries, forming the venous plexus 
of Santorini [205]. No tributaries, however, come from the 
parietal veins of the pelvis. This plexus lies chiefly on the 
anterior and lateral aspects of the prostate, and its veins, like 
others in the pelvis, and in spite of the large number of valves 
present, are prone to become engorged. In the aged they fre- 
quently become varicose, and the formation of phleboliths is not 
at all uncommon. 

This plexus lies within the meshes of the sheath of the pros- 
tate, entirely outside of its capsule. Its veins travel backward, 
receiving veins from the sides and base of the bladder, and from 
the cellular tissue about the rectum, and finally empty into the 
internal iliac veins. Fenwick [76] has shown that this important 
plexus has three distinct sets of valves, which all tend to prevent 
backward pressure. One set is found at the commencement 
of the system; one at the end, in the internal iliac veins; and a 
third set, which is less constant, about the middle of the plexus. 



Vascular Supply. 33 

Practically all the veins which enter this plexus are valved, so 
that Fenwick compares the condition to that of a series of rooms 
with many different entrances, but only one exit, the result being 
that the direction of the current is normally always straight 
onward. The branches received from the internal pudic veins 
and from the perirectal veins are powerfully valved, so that 
normally no regurgitation into the hemorrhoidal circulation can 
take place. 

The Arteries. — The arteries of the prostate are numerous 
but insignificant. They arise from the internal pudic, inferior 
vesical, and middle hemorrhoidal arteries. The largest is the 
vesico-prostatic artery, derived from the inferior vesical, passing 
along on the lower part of the sides of the bladder to the pros- 
tate. The twigs given off from this artery on the surface of the 
prostate in part supply its substance, piercing its capsule, and 
in part anastomose with twigs from the corresponding artery on 
the opposite side, above the prostate. There are seldom many 
communicating branches below the gland, while the branches 
from the internal pudic and middle hemorrhoidal are rarely of 
sufficient size to be noticed. 

Sometimes the internal pudic artery is smaller than usual, 
and its terminal branches are then derived from the vesico-pro- 
static, or from an accessory pudic artery, rising from the internal 
pudic artery just before its passage through the great sacro- 
sciatic foramen. When they are derived from the accessory 
pudic, they may be wounded in operations on the perineum; 
but when springing from the vesico-prostatic, they lie above the 
prostate and urethra, and are not so liable to injury. 

The Nerves. — The nerves are largely derived from the sym- 
pathetic system through the pelvic or inferior hypogastric plexus, 
some medullated fibres being found also. These last are derived 
chiefly from the third sacral nerve, but also to some extent from 
the second and fourth. The nerves accompany the arteries, 
lying between the prostate and the levatores ani in their forward 
4P 



34 Anatomy. 

course. The bladder, the urethra, and the cavernous tissue of 
the penis receive their nerve-supply from the same source; and 
thus the reflex pains felt at the end of the penis, in certain affec- 
tions of the bladder, are readily accounted for. 

The Lymphatics. — The lymphatics are both deep and super- 
ficial. The former accompany the smaller vessels in the stroma 
of the gland, while the superficial series lies with the venous 
plexus between the prostatic capsule and its sheath. These are 
eventually joined by the deep vessels, and they together empty 
into the lymphatics along the course of the internal iliac vessels. 

Microscopical Anatomy. — Histologically the prostate is 
classed as a compound tubular gland. The acini are embedded 
in a meshwork of involuntary muscle and fibrous tissue, this latter 
extending as septa inward from the prostatic capsule, which is 
formed by a peripheral condensation of the stroma of the organ. 
Among the muscular and fibrous tissues and around the acini 
are found the arterial twigs, the venous radicles, and the deep 
set of lymphatic vessels. The ultimate distribution of the nerves 
is not definitely known. 

The glandular tissue is most marked in the two lateral lobes 
of the prostate beneath the urethra, and is in greater evidence 
toward the apex than the base of the organ. In the portion 
of the prostate anterior to the urethra there is little glandular 
tissue; this part as well as that immediately beneath the urethra 
representing the areas of coalescence or the commissures of the 
two lateral lobes, and being almost wholly composed of muscular 
and fibrous tissue. Sometimes gland tubules are found below 
the urethra and above the ejaculatory ducts, forming the so-called 
third lobe of the prostate ; but more usual is it for glandular tissue 
to be absent in this region. 

The muscular tissue of the prostate, as shown by Hodgson 
[122] and by Griffiths [104], is a continuation, more or less 
direct, of the circular layer of the bladder; the outer vesical 
layer, which is longitudinal in direction, ceasing at the level of 



Histology. 35 

the urethral orifice. This circular layer has become displaced 
by the growth into it of the glandular tissue, which arose from the 
mucous lining of the urethra; accordingly the ducts of the pros- 
tate are found to be devoid of a special muscular investment, 
whereas the acini have a layer of involuntary muscle surrounding 
them throughout their extent. 

The muscular fibres of the prostate are arranged as a com- 
pact layer around its periphery, forming with the contiguous 
fibrous tissue the true capsule of the gland; and also circularly 
around the urethra, acting here as the muscularis mucosae; while, 
finally, there is a poorly marked longitudinal layer of involuntary 
muscle just external to the urethral muscularis mucosae. There 
are thus in the prostatic urethra three coats of involuntary muscle ; 
the most internal is circular, and forms the muscularis mucosae; 
the middle, poorly developed, is longitudinal, and is really a 
continuation of the muscles of the ureters; while dispersed 
throughout the gland is found an outer circular layer, which 
may be recognized as the circular coat of the bladder. 

This description is that generally given, and most widely 
received. It is well to note, however, that Pettigrew [192] pro- 
posed the ingenious theory that all the fibres of the bladder are 
really in a figure-of-eight form, in seven layers. Of these layers, 
he asserted that the fibres of the central crossed so very obliquely 
that they appeared circular; while the fibres composing the 
three external and the three internal layers are of different degrees 
of obliquity, so that the most internal and the most external 
appear longitudinal. The muscle of the prostate, according to 
this view, is derived from the outer halves of the three external 
vesical layers, while the internal halves of these layers enclose 
the prostatic urethra immediately outside of its usually recog- 
nized muscular coats, which, Pettigrew says, are really the cen- 
tral and three internal layers of the bladder. 

Wallace [240] asserts that striped as well as unstriped mus- 
cular fibres are found among the glandular tissue of the normal 
prostate. 



36 Anatomy. 

The gland ducts are lined close to their orifices at the urethra 
with a prolongation of the usual transitional epithelium of this 
canal; deeper in they are lined by a single layer of columnar 
epithelium, but possess no distinct basement membrane. They 
often penetrate the urethral walls obliquely. In infants ducts 
only are found, no acini having developed. 

The acini themselves are paved with columnar epithelium, 
which, though usually in a single layer, is frequently stratified, 
smaller pear-shaped or polyhedral elements filling up the crevices 
between the columnar cells. The nuclei of these acinous cells 
are placed nearer to the basement membrane than to the free 
end of the cells. The cells are often granular in appearance. 

Walker [235] has described collections of small round cells 
in the prostate. These he regards as lymph nodes; but he has 
not succeeded in demonstrating lymph channels, except at the 
periphery of the gland. His observations do not appear to have 
been confirmed by other investigators, who regard Walker's lymph 
nodes as evidences of inflammation. 

Elastic tissue also is found in the prostate, lying circularly 
around the urethra, and sending figure-of-eight processes out 
around the prostatic ducts, just beneath the mucous membrane. 

The uterus masculinus is an oval or rounded saccule, about 
one-fourth or one-third of an inch in length, lined with mucous 
membrane containing small tubular glands homologous with 
those of the female womb. It possesses, moreover, a thin layer 
of involuntary muscle, and is contained within a dense fibrous 
envelope of its own. Its orifice will admit the tip of a small 
probe or catheter. 

The prostatic urethra extends from the bladder above to the 
deep layer of the triangular ligament below, where it becomes 
the membranous urethra. Its course is at first downward, but 
toward the termination of the membranous portion it has com- 
menced its upward journey, which is continued in the bulbous 
portion until the penile urethra is reached, when the curve again 



PLATE XIV. 




Urethra and Bladder Laid Open from Above, showing in Bulbous Urethra 
the Orifices of the Ducts of Cowper's Glands, and in the Prostatic Ure- 
thra the Orifice of the Uterus Masculinus, with the Openings of the 
Prostatic Ducts on Each Side of the Verumontanum. Note the Orifices 
of the F.jaculatory Ducts on the Margins of the Orifice of the Uterus 
Masculinus. 



PLATE XV. 



Peritoneum 

oneurosis °f Denoiwiitiers 




Prostate 
Ant. layer °/7ri, angular liyament 
rost. /ayer °J ' 7?ias?.<?u/,ar fopament 

Sheath of Prostate in Sagittal Section (Diagrammatic). 



PLATE XVI. 



Jfecto-vesicat fascia *"V^v 
1st. Division ^^ ) \ 
2nd. Division^/ J 
3rd. Division^ 




Obturator 
Interims 

Analfascia 
ZeoaforAni 



vessels & nerve . 




Sheath of Prostate in Transverse Section. Line^of Section shown in the 

Lower Drawing. (Diagrammatic.) 

Compare with Plate XIII. 



PLATE XVI 




Normal Urethra, showing Dilatability. 
A. Fossa navicularis. D. Bulbous urethra. B. Membranous urethra. C. Prostatic 

urethra. 



PLATE XVIII. 




Coronal Section of the Pelvis, through the Prostate and the Membranous 
Urethra, showing the Triangular Ligament of the Perineum. View of 
the Anterior Surface of the Posterior Segment of the Pelvis. — (Spalte- 
holz.) 



PLATE XIX. 




View of the Pelvis from Behind. 
Notice the white line of origin of the levator ani; the relations of the ureters, vasa 
deferentia, and seminal vesicles. The prostatic sheath is well shown, also the two layers 
of the recto-prostatic fascia (aponeurosis of Denonvilliers), and between them the deep 
layer of the triangular ligament. 



Applied Anatomy. 37 

changes, and here has its convexity upward. The prostatic 
urethra is from three-fourths of an inch to an inch in length, 
and normally has its sides in contact. Its floor is raised by the 
verumontanum or caput gallinaginis so that on cross- section it 
presents a crescentic outline, with convexity above. Its internal 
diameter is about one-third of an inch (eight millimetres), but 
it is the most dilatable part of the whole canal. On its superior 
wall, just beneath the mucous membrane, are numerous good- 
sized veins, which, when engorged, may easily be ruptured by 
a catheter carelessly passed. The caput gallinaginis is partly 
composed of erectile tissue, which by its turgescence during 
sexual excitement is supposed to prevent reflux of semen into the 
bladder. The mucous membrane of the prostatic urethra is 
convoluted into longitudinal folds when no urine is passing, and 
is hence readily adapted to changes in calibre of this canal. 

Relational or Applied Anatomy. — Although the state of 
the parts surrounding the prostate is of greater anatomical interest 
to the surgeon when altered by disease, yet a clear understanding 
of such pathological changes is only to be acquired by a thorough 
knowledge of the normal relations. 

Placed in the true pelvic cavity, below the bladder, above 
the rectum, and about half an inch behind the lower margin of 
the pubic symphysis, the prostate is held quite firmly in place 
by the supporting fasciae. 

From the bladder it is separated only by a thin layer of fascia 
(the first of the three subdivisions of the recto-vesical fascia) 
which becomes blended with both the outer coat of the bladder 
and, in the middle line, with the capsule of the prostate. Hence 
on incising the mucous membrane of the bladder, as soon as the 
muscularis mucosae is divided, this layer of fascia presents itself, 
forming the sheath of the prostate ; and as there are in this situa- 
tion no veins of any size between the prostatic sheath and its 
capsule, the sheath and capsule are here practically in contact. 
When the prostate becomes much enlarged, this layer of fascia 



38 Anatomy. 

atrophies or is pushed to one side, and the prostatic capsule 
presents itself immediately beneath the vesical mucous mem- 
brane. 

To the rectum the prostate is rather firmly attached by 
fibrous connective tissue, which may, with care, be separated 
into two layers, prolongations of the recto- vesical fascia; the 
lower layer blends with the fibrous covering of the rectum, while 
the upper sends processes around the seminal vesicles and am- 
pullae of the vasa deferentia, besides passing below the prostatic 
plexus of veins to join a similar layer from the other side. This 
layer remains after the removal of the gland by suprapubic pros- 
tatectomy, and, with that immediately subjacent, effectually 
prevents urinary extravasation into the perirectal and subperi- 
toneal cellular tissues. These two layers of fascia form together 
the aponeurosis of Denonvilliers [62], and the rectum cannot be 
safely stripped back from the prostate in the operation of perineal 
prostatectomy until the inferior layer, which is the stronger, has 
been divided; by so doing the surgeon is admitted into the 
"espace decollable retroprostatique," so eloquently described by 
Proust [196]. 

The recto-vesical fascia forms in the median line anteriorly 
two thicker bands of fascia, known as the pubo-prostatic ligaments 
or anterior true ligaments of the bladder. These are attached 
above to the pubic bones on each side of the symphysis, and are 
inserted below into the capsule of the prostate on its upper sur- 
face, and into the anterior surface of the bladder. When I say 
inserted into the capsule of the prostate, I wish it to be under- 
stood that here, as elsewhere, the prostatic plexus of veins lies 
immediately outside the capsule of the prostate gland, and that 
the insertion above described takes place by processes of fascia 
sent between the veins where they are numerous, and by a coales- 
cence of the sheath with the capsule where the veins are absent. 
The dorsal vein of the penis, after perforating the deep layer of 
the triangular ligament of the perineum, lies in the interval be- 



Applied Anatomy. 39 

tween the two puboprostatic ligaments, and as they pass on to 
their insertion into the bladder, it subdivides beneath them into 
the prostatic plexus. Because fibres of involuntary muscle, pro- 
longed from the bladder-wall, are found beneath the pubopros- 
tatic ligaments, they are also called the pubo-prostatic muscles. 

In the median line anteriorly the recto- vesical fascia (pubo-pros- 
tatic ligaments) is in contact beneath the pubic arch with the 
deep layer of the triangular ligament of the perineum (the dorsal 
vein of the penis intervening); but to each side of the median 
line these structures are separated by the most anterior fibres 
of the levatores ani muscles, which in this situation were denomi- 
nated by Santorini [204] the levatores prostatas. These mus- 
cular fibres descend upon the sides of the prostate, and unite 
beneath it; in this situation they blend with the fibres of the 
superficial transverse perineal and external sphincter ani muscles, 
forming the central tendinous point of the perineum. The deep 
layer of the triangular ligament, it should be remembered, is 
really one of the ultimate subdivisions of the pelvic fascia, being 
the continuation toward the median line of the obturator fascia, 
which lies between the levator ani and the obturator internus 
muscles. 

The urethra emerges from the prostate gland at its apex, 
about half an inch below the pubic arch. It here passes through 
the posterior or deep layer of the triangular ligament and be- 
comes the membranous urethra. This layer of fascia is firm 
and tense, and accordingly the apex of the prostate gland is its 
most fixed portion; enlargement of the organ necessarily extends 
backward, upward, or downward, never forward. There is no 
sharp ring where the urethra penetrates the triangular ligament, 
as this membrane, instead of terminating abruptly at the circum- 
ference of the urethra, is reflected along its surface toward the 
prostate, and blends with its fibrous coat. Thus a catheter is 
not liable to be arrested by any ring-like constriction outside the 
lumen of the urethra. 



40 Anatomy. 

The prostatic urethra is normally about seven inches distant 
from the external urinary meatus. Any obstruction seated nearer 
than this to the meatus is not likely to be caused by disease of 
the prostate. 

About one and a half inches within the anus the prostate 
may be felt as a rounded, firm body of about the size of a horse- 
chestnut or a little larger. By combined examination with a 
sound in the urethra and a finger in the rectum much informa- 
tion as to its size and shape may be obtained. 

It is well known that the anterior wall of the rectum under- 
goes a sharp flexure just within the anus, so that the axis of the 
rectum is practically at right angles with that of the anus. This 
angle of the anterior rectal wall is produced by its attachment 
to the triangular ligament of the perineum by certain muscular 
fibres described as the recto-urethral muscle. The external 
sphincter of the anus, it will be recalled, is attached anteriorly 
to the perineal centre, meeting there with the superficial trans- 
verse perineal muscles from the sides, with the anterior fibres 
of the levatores ani muscles from a deeper plane posteriorly, 
and with the bulb of the urethra anteriorly. On a plane just 
beneath these structures are met the recto-urethral muscle pos- 
teriorly, and the triangular ligament containing the deep trans- 
verse perineal muscles (constrictor urethrae) anteriorly. To 
understand how the levator ani, which between the space of 
Retzius and the pubic symphysis is on a deeper plane than the 
triangular ligament, can become superficial to this structure 
and the recto-urethral muscle, it must be remembered that the 
levator ani is like a sling, and hangs down from the pubic bones 
to surround the anus, being deficient in the median line under 
the pubic arch, and only becoming superficial to the triangular 
ligament back of the posterior border of this structure, where 
its fibres from the two sides of the prostate unite at the perineal 
centre. The accompanying illustration (Plate xxi) shows these 
relations very well. 



PLATE XX, 




^ 8 

X3 &h 



55 ^ 






aa 

o 



X 



w 









o '5? 



GO o 



PLATE XXI. 




Side View of the Pelvis showing the Muscles around the Bladder and Prostate. 
A. Triangular ligament. B. Levator ani muscle of right side. C. Deep transversus perinei 
muscle of left side. D. Cut edge of levator ani muscle of left side. E. External sphincter ani 
muscle. F. Bulbo-cavernosus muscle. G. Left ureter. H. Vas deferens (left). K. Coccygeus 
muscle (right). L. Pyriformis muscle (right). The bladder and prostate have been displaced 
upward so as to expose the levator ani. 



Applied Anatomy. 41 

The recto- vesical fold of peritoneum reaches, when the blad- 
der is empty, as far as the base of the prostate, or nearly so ; but 
when the bladder is distended with a moderate amount of fluid, 
the peritoneal reflection is probably always at least one and a 
half inches above the base of the prostate gland. This explains 
how the bladder was formerly tapped through the rectum with 
such success, and shows that in any ordinary operation on the 
prostate through the perineum no fear need be entertained of 
opening the peritoneal cavity. 

The anterior vesical fold of peritoneum is carried up about 
two inches above the upper margin of the symphysis pubis by 
moderate distention of the bladder; but as in suprapubic opera- 
tions the peritoneum is usually recognized with ease, if seen at 
all, and may readily be stripped off from the bladder if more 
room is desired, the relations here are not of such practical in- 
terest. * 

The ampullae of the vasa deferentia lie between the two 
seminal vesicles upon the rectum, and beneath the neck of the 
bladder, just back of the prostate gland, where they may be 
felt by a ringer in the rectum. The ureters lie above and on 
their outer side; and in the small area between the prostate 
anteriorly, the vasa deferentia at the sides, and the peritoneal 
reflection above or posteriorly, the bladder is in fairly close re- 
lation with the rectum. This is the spot where, when fluctua- 
tion could be detected, the bladder was formerly punctured for 
retention of urine. 

The combined ejaculatory duct of the vas deferens and seminal 
vesicle of each side penetrates the prostate gland through a trans- 
verse fissure on its inferior surface; the two ducts then run for- 
ward, and empty side by side into the floor of the prostatic 
urethra. They pass through the posterior commissure of the 
two lateral lobes, an area composed almost entirely of fibrous 
and muscular tissue. According to Mr. Freyer [89], when 
the prostate undergoes marked adenomatous change, its two 



42 Anatomy. 

lateral lobes tend to become again separated, as they were during 
foetal life ; and hence under such conditions it is not theoretically 
absurd to consider that the two lateral lobes could be shelled 
off the ejaculatory ducts, leaving their attachment to the urethra 
intact. That such is ever the case during life is, however, in 
the highest degree improbable. Young [261] has pointed out 
that in enlargement of the prostate these ducts are situated 
relatively nearer the inferior surface of the prostate than in health, 
and he advocates an operation by which the mass of prostatic 
tissue containing them is left attached to the urethra. Since it 
is probable, as will be seen in the next section, that the seminal 
fluid has no fertilizing power when unmixed with that from the 
prostate, and for other reasons of a less sentimental nature, it 
appears to me extremely doubtful whether any attempt to pre- 
serve the continuity of the ejaculatory ducts with the urethra 
in operations on the prostate gland is at all advisable. 

Physiology. — That the prostate gland is functionally a part 
of the generative rather than of the urinary tract is evident from 
the various points brought forward in connection with its embry- 
ology and comparative anatomy. What its exact function is, 
however, remains an undecided question. Prostatic fluid, as 
long ago noted by Haller [109], Morgagni [166, 167], and Hun- 
ter [128], is useful chiefly as an accessory and diluent of the tes- 
ticular secretion and of the fluid derived from the seminal vesicles. 
Testicular fluid is alkaline in reaction, and, as pointed out by 
Adams [1], that of the prostate is acid; hence it may be inferred 
that the fluid from the prostate is useful in neutralizing the 
alkalinity of the testicular secretion. In perfect accord with 
this reasoning are the experiments of Fiirbringer [93], who showed 
that spermatozoa which were motionless when no admixture 
of prostatic fluid was present, were excited to action by the 
addition of a moderate quantity; while the addition of larger 
amounts killed them. Steinach [215], moreover, has shown that 
the removal of the seminal vesicles and the prostate gland from 



PLATE XXII. 





Side View of the Pelvis, showing the Relations of the Peritoneum to the 
Empty and the Distended Bladder. — (After Cerrish.) 



PLATE XXIII. 




Dissection oe the Perineum. 
The attachment of the external sphincter ani to the perineal centre has been divided, 
and the fascia of Colles has been reflected, exposing the superficial vessels and nerves 
of the perineum, the superficial transverse perineal muscles, the ischio-cavernosus and 
the bulbo-cavernosus muscles. Posteriorly, on each side of the anus are seen the leva- 
tores ani muscles, clothing the sides of the rectum; on the subject's left the internal pudic 
artery and branches of the pudic nerve are seen. 



PLATE XXIV, 




Dissection of the Perineum. 
The superficial transverse perineal muscles, the bulbo-cavernosus muscle,- and the 
right ischio-cavernosus muscle, have been removed, together with part of the right cor- 
pus cavernosum and a section of the corpus spongiosum and urethra. The superficial 
layer of the triangular ligament, the dorsal vein, artery and nerves of the penis, and the 
arteries of the corpus cavernosum, are thus exposed. 



PLATE XXV. 




Dissection of the Perineum. 
The superficial layer of the triangular ligament has been incised, exposing the deep 
transversus perinei muscle on the left side, and the internal pudic vessels and nerve on 
the right side of the cadaver. The duct of Cowper's gland of the right side is seen as 
it enters the bulbous urethra, after piercing the superficial layer of the triangular liga- 
ment. 



Physiology. 43 

white rats, " while not diminishing the sexual passion and the 
ability to perform the sexual act, including the actual discharge 
of spermatozoa, prevents entirely the fertilization of the ova; 
removal of the seminal vesicles alone markedly weakens the 
fertilizing power of the semen." 

It is not known whether the prostate furnishes an internal 
secretion to the body; that it furnishes one of any considerable 
consequence is at all events unlikely. Its removal has about 
as much apparent effect on the functions of the body as has 
that of the vermiform appendix; yet it is believed by some that 
the appendix furnishes an internal secretion. 

Concretions are frequently found in the prostatic acini in 
advanced life. Their nucleus is probably mucoid material and 
epithelial cells; while the concentric layers of mineral matter 
are formed from the prostatic secretion. The amount of earthy 
matter in these concretions has been estimated at from 46 to 
86 per cent. Prostatic fluid itself contains only about 1.5 per 
cent, of solids, which are mostly proteids and salts. Some of 
the most recent researches into the physiology of prostatic secre- 
tion are those of Stern [216], who thinks its normal reaction is 
alkaline, acidity being a sign of disease. 

At birth and until puberty the prostate is small, and contains 
more muscular tissue in relation to the glandular than is the 
case in later life. At puberty the increase in size of the prostate 
is proportionate to that of the rest of the sexual apparatus; the 
glandular tissue at the same time developes from the mere ducts 
present in childhood until well-formed acini are found. 

During sexual excitement the caput gallinaginis becomes 
turgid, and, possibly with the aid of the contraction of those 
fibres of the prostate nearest the bladder, shuts off this viscus 
from the prostatic urethra. .Powerful rhythmic contraction of 
the prostatic muscle follows, and the prostatic fluid is forced 
into the urethra, to dilute and give bulk to that arriving through 
the ejaculatory ducts. Contraction of Henle's [120] muscle 



44 Anatomy. 

(external sphincter of the bladder) and of the deep transverse 
perineal muscles (constrictor urethrae) aids in the expulsion for- 
ward. 

As middle life passes and old age advances some general 
enlargement of the prostate gland may be considered nearly 
universal, so frequently does it occur. That it is not normal, 
however, is clear from the fact that some diminution in size 
occurs in all the other generative organs, as the sexual life draws 
to a close ; much in the same way that the generative organs of 
those animals who have a rutting season decrease in size when 
that season is passed. 

The prostate gland is normally quite passive during urina- 
tion. Functionally the prostatic urethra is part of the bladder, 
whose true sphincter is the voluntary muscle placed around 
the membranous urethra (constrictor urethrae, or deep transverse 
perineal muscles), aided perhaps by those fibres of voluntary 
muscle known by Henle's [120] name (external sphincter of the 
bladder), and situated about the apex of the prostate gland just 
posterior to the deep layer of the triangular ligament. As urine 
accumulates in the bladder, the natural elasticity of the parts 
excludes it from the prostatic urethra. When the natural elas- 
ticity, the muscular tone of the bladder, or whatever we choose 
to call it, is overcome, then the urine enters the prostatic urethra, 
and meets with an obstruction from the voluntary muscle around 
the apex of the prostate (Henle's muscle) and the membranous 
urethra (constrictor urethrae). As Moullin [176] has pointed 
out, the voluntary muscles here are stronger than is the case 
with the anal sphincters. There the ever increasing desire 
to defaecate overcomes the voluntary sphincter (external); but 
the constrictor urethrae generally holds tight, and the involuntary 
muscle of the bladder gives in, and the urine is retained, until 
a sufficient increment of urine has collected, when the process 
may be repeated. When a perineal section is done for an im- 
permeable stricture, no urine flows until the membranous urethra 



PLATE XXVI. 




Dissection of the Perineum. 
The bulb of the urethra and the Jeft deep transversa perinei muscle have been re- 
moved On the subject's left the deep layer of the triangular ligament is exposed. On 
the right Cowper's gland is seen. 



PLATE XXVII. 




Dissection of the Perineum. 



The deep layer of the triangular ligament, with all structures superficial to it, has 
been removed, exposing the perineal portion of the levator ani muscle and its anterior 
fibres known as the levator prostata 3 . The urethra has been cut off at the apex of the 
prostate gland. The fibres of the levator ani passing underneath the rectum are shown 
as in the preceding plates. 



PLATE XXVIII. 




Dissection of the Perineum. 
The rectovesical fascia, forming the sheath of the prostate, and the levator ani 
muscle, have been incised from the symphysis to the anus, and the rectum has been 
turned backward. The prostate, the seminal vesicles, and the vasa deferentia are ex- 
posed. Note the vesico-prostatic plexus of veins in the meshes of the recto-vesical fascia. 
The wall of the bladder is seen above the prostate. 



Physiology. 45 

has been divided ; it is not necessary to enter the bladder, whose 
cavity now, when overdistended, functionally extends as far as 
the triangular ligament. Likewise if a catheter is passed while 
the patient is straining to urinate, urine will begin to flow as soon 
as the prostatic urethra is reached; but if no desire to urinate 
is present, the catheter must be passed its full length into the 
bladder before urine flows. In patients with enlarged prostate 
who are able to make water this test provides a very simple and 
fairly accurate way to determine the length of the prostatic 
urethra. 

During urination the muscles of the ureters — longitudinal 
bands prolonged from the ureters to the uvula vesicae and veru- 
montanum — contract, and by their action tend to lower the 
vesical orifice of the urethra and to raise the neck of the blad- 
der, thus effectually opening the prostatic urethra, and making 
it bear the same relation to the bladder that the spout of a funnel 
does to its cone. It was a favorite theory of Mr. Reginald Har- 
rison's [116] that the prostate aided in expelling the last 
drops of urine, and that the lower the neck of the bladder sub- 
sided below the urethral orifice, the harder was the work thrown 
on the prostate, which accordingly underwent compensatory 
hypertrophy in its vain endeavours to expel the residual urine. 
That such a theory is untenable I think is manifest from the 
various facts already set forth, for it is undoubtedly true that 
the prostate is entirely passive during micturition, and only 
contracts during the sexual orgasm. 



CHAPTER III. 
PATHOLOGY AND ETIOLOGY. 

The subjects of pathology and aetiology of enlargement of 
the prostate are so intimately connected that it has seemed best 
to consider them together, reserving those of clinical pathology 
and clinical causes for later chapters. 

It is a mortifying confession to make, but it is undoubtedly 
true, that little has been added to our knowledge of the pathology 
of enlarged prostate within the past fifty years. Those who will 
read Hodgson's book, for instance, or Sir Henry Thompson's 
work, and then turn to the most recent expositions of the subject, 
will find that very few, if any, of the statements made or the 
theories advanced can be considered in any way an advance 
from these masterpieces. Yet among all the heterogeneous and 
at times bewildering arguments promulgated, one fact is prom- 
inently seen, that any solution of the difficulty is not to be looked 
for in repeating and reiterating the old theories proposed on 
a priori grounds: to set the subject of pathology in a state even 
remotely approaching that of order, we need the detailed study 
of individual cases; and when we have this, then we may build 
up our theories a posteriori. By this I mean that it is not suffi- 
cient to start out with the theory that enlargement of the prostate 
is merely a local manifestation of general arteriosclerosis, as 
claimed by Guyon [108] and his school; nor to pronounce all 
such cases precisely similar to those of fibroid tumors of the 
uterus, with Velpeau [232], Paget [188], Billroth [23], and their 
followers; nor, furthermore, to say that the primary change 
consists in descent of the floor of the bladder, and that the enlarge- 
ment of the prostate is in the nature of a compensatory hyper- 

46 



^Etiology. 47 

trophy, as asserted by Reginald Harrison [116]. It is certain 
that no one of these theories will suit every case, although I have 
little doubt that each may express the true causes operative in 
certain individual patients. 

Probably no one observer has seen a sufficient number of 
cases to enable him to deduct authoritative conclusions; but 
what is needed is a collective investigation of large groups of 
cases, which have been reported in such detail, and with such 
completeness, that a general view may be had of the type of the 
enlargement; its duration; the clinical history of the case, in- 
cluding previous local diseases, such as gonorrhoea, prostatitis, 
calculus, etc., and the social habits; as well as a microscopical 
study of the diseased organ removed either by operation or at 
autopsy. I am not aware of any such investigations; and as 
our knowledge is thus unfortunately limited, a satisfactory exposi- 
tion of the pathology of the prostate gland is a chapter which 
is still unwritten. The older observers, Home [123], Mercier 
[159], Desault [66, 67], and others, made quite complete clinical 
records of their cases ; and some very elabourate and painstaking 
histological studies have been made within recent years, notably 
by Ciechanowski; but each series is incomplete — the former, 
because no microscopical studies were possible; the latter, be- 
cause the clinical histories of the patients are unknown, except 
in a very few instances. If the patient gives a history of repeated 
attacks of posterior urethritis and prostatitis, we desire to learn 
by the microscope whether the changes in the prostate gland 
present the usual characteristics of " senile enlargement." On 
the other hand, if we find by the microscope groups of small 
round cells, catarrhal proliferation, and fibroblasts changing into 
scar tissue, we desire to know whether the patient in life suffered 
from prostatitis or posterior urethritis, or whether such changes 
arose without apparent cause. 

It appears in some respects that our ideas in regard to the 
pathology of this condition have become rather less positive in 



48 Pathology. 



PLATE XXIX. 

The patient, A. H., aged sixty-three years, was admitted to the German 
Hospital April 24, 1904. Has always been healthy, and his habits have been 
good. For over two years he has been passing urine frequently, and during 
the last six months he has been forced to make water every fifteen or twenty 
minutes during the day, and has had to get up from six to eight times every 
night. Although he has occasionally suffered with retention of urine, he has 
never had a catheter passed, always being able eventually to evacuate his 
bladder voluntarily. Two weeks ago, however, one of these attacks necessi- 
tated catheterization. One week later another attack of retention occurred, 
whereupon the physician in attendence instituted permanent drainage by an 
in-lying catheter. 

On admission examination showed that the prostate was the size of an 
orange, hard, and not readily movable. 

Suprapubic prostatectomy was done on April 28, 1904. The bleeding was 
free, but was controlled at the time by irrigation with hot solution. On the 
following night the haemorrhage recurred and was twice temporarily con- 
trolled by hot douching; the third haemorrhage was checked by packing the 
bladder. But the patient did not react from the loss of blood, and died the 
following day. 

The prostate, No. 1866, shown in the accompanying Plates, is a very large 
one, of the glandular type; its weight was 145 grammes (about 5 ounces). 



PLATE XXIX. 




View of the Under Surface of an Enlarged Prostate (Xo. 1S66), Measuring 
7 X 6.5 X 6 cm. (2! X 2f X -4 Inches) and Weighing 145 Grammes (about 
5 Ounces). A Catheter has been Introduced through the Urethra. 



PLATE XXX. 




View of the Upper Surface of an Enlarged Prostate (No. 1866), Measuring 
7 X 6.5 X 6 cm. (2f X 2§ X 2| Inches) and Weighing 145 Grammes (about 
5 Ounces). The Ends of a Catheter Introduced through the Urethra 
are Visible. 



^Etiology. 49 

proportion to the increase of our knowledge in other respects. 
The early writers had little doubt that the main cause of pros- 
tatic hypertrophy was chronic inflammation, chiefly blenor- 
rhagic in origin; then came the theories already mentioned of 
general arteriosclerosis, of adenomyomatous changes, and of 
compensatory hypertrophy. None of these being entirely satis- 
factory, it was considered that the two main varieties of enlarge- 
ment — adenomatous and fibrous — were different stages of the 
same process. But as not even this seemed a sufficient explana- 
tion, most recent writers have returned to the original view of 
an inflammatory cause, and reject altogether the adenomatous 
theory. 

Nevertheless, practically every one is agreed that there do 
exist two main pathological characters under which enlargement 
of the prostate gland is seen: one where there is a dispropor- 
tionate increase in the glandular elements — a pseudo-adenomatous 
change; and the second where an increase in the stroma of the 
organ is conspicuous. In either case the increase may be local 
or general, or both processes may coexist, one exceeding the other 
in different parts of the same organ. 

But while, therefore, these two main classes of pathological 
change are recognized, some observers have held that they were 
totally independent; whereas, as already indicated, others have 
pointed out in the general overgrowth, as a rule almost exclusively 
fibrous in character, merely an advanced stage of the adenomatous 
variety. Such was the theory originated by Dodeuil [73], and 
advocated by Griffiths [104] and by Moullin [176], and that which 
has been supported more recently by Alexander [5]. But it 
does not appear to be to me a reasonable theory upon the face 
of it; nor, so far as I am able to learn, has it ever been satisfac- 
torily demonstrated by tracing an individual prostate through 
both stages. On the contrary, the patient with the fibrous and 
hard prostate, of small or moderate size, usually comes to the 
surgeon with a history of shorter urinary trouble than does he 
5? 



50 Pathology. 



PLATE XXXI. 

The patient, P. J., aged sixty-five years, was admitted to the German 
Hospital March 5, 1904. For a long time he has had frequent urination, day 
and night. Four weeks before admission to the hospital acute retention de- 
veloped; since that time he has had to be catheterized, twice daily at first, 
lately three times a day. 

Examination on admission shows the prostate to be moderately enlarged. 
The residual urine amounted to 300 cc. (10 ounces). 

After a preliminary meatotomy on March 12, the operation of suprapubic 
prostatectomy was performed March 20, 1904. Recovery was uneventful 
but rather tedious. 

The prostate, No. 18 10, shown in the accompanying Plate, was small and 
fibrous, weighing only 30 grammes (1 ounce). 



PLATE XXXI, 




View of an Enlarged Prostate (No. 1810), Measuring 4X3X3 cm. (i£ X ij 
X i| Inches) and Weighing 30 Grammes (i Ounce). A Catheter has been 
Introduced through the Urethra. 



^Etiology. 51 

whose organ is affected by adenomatous change; and the reverse 
would be anticipated were the fibrous the terminal stage. It is 
not unusual for the patient with a large spongy prostate to give 
a history of urinary difficulty of from ten to fifteen years' dura- 
tion, or even longer; while one with a fibrous prostate will gener- 
ally seek relief within a couple of years. And it is incredible 
that this last mentioned patient should have progressed to the 
second stage of the disease, as it is called, without having had 
symptoms during the preceding period when his prostate is pre- 
sumed to have been soft and adenomatous, and possibly larger. 
I have examined the records of 50 cases in regard to this point, 
and find that of 40 belonging to the adenomatous group the aver- 
age duration of symptoms before operation was over nine years; 
while in 10 of the fibrous class it was less than five and a half 
years. 

T do not mean to imply that the glandular form succeeds 
upon the fibrous; for it seems to me that these two varieties are 
entirely distinct in their evolution, their clinical history, and their 
treatment. 

The case is not altogether the same in the prostate as in the 
kidney, for example; and yet the sclerosis of interstitial neph- 
ritis, where fibrous tissue takes the place of secreting structure, 
has^often been compared to the fibrous changes found in the 
prostate gland. The question remains unsettled, whether fi- 
brous overgrowth in the kidney is the cause or the result of the 
atrophy of the renal tubules; but it appears to me by no manner 
of means reasonable to suppose that an overgrowth in pseudo- 
adenomatous fashion of secreting structure, which in the pros- 
tate is acknowledged to be the first occurrence, should at a 
later date be caused to atrophy and be replaced by a fibrous 
growth. 

If, then, we look upon these two forms of enlargement as 
distinct from beginning to end, we are still at a loss for an effi- 
cient cause for either. As has already been seen, a number 



52 Pathology. 



PLATE XXXII. 

The patient, L. F., aged sixty-eight years, was admitted to the German 
Hospital June 30, 1903. No venereal history was obtained. His bowels were 
regular; he was a moderate user of tobacco ; no alcohol. One week ago he had 
had an infection of the middle finger of the left hand. For the past two years 
the patient has had trouble in passing his urine, being often obliged to get up 
eight or ten times during the night to empty his bladder. He had suffered from 
some burning upon urination, and had difficulty in starting the stream. Four 
days before admission he developed acute complete retention, and a catheter 
was passed only with the greatest difficulty. 

On admission 600 cc. (20 ounces) of bloody urine were withdrawn; a 
false passage was detected in passing the catheter. Rectal examination 
showed an enlarged prostate quite firm to the touch. The operation of 
suprapubic prostatectomy was undertaken one week later, July 6, 1903. The 
wound healed promptly, and the patient was discharged September 11, 1903, 
entirely relieved of his urinary symptoms. 

The prostate, No. 1533, is shown in the accompanying Plate. 



PLATE XXXII. 




View or an Enlarged Prostate (No. 1533), Measuring 6 X 6 X 4.5 cm. (2% X 2\ 
X if Inches). A Catheter has been Introduced through the Urethra. 



Size and Direction of Growth. 53 

of pathological processes have been held responsible for the 
enlargement; and these theories all range themselves under 
two heads: in one the enlargement is held to be primary — to 
be itself a cause — to arise de novo; and in the other it is con- 
sidered a secondary change — as the result of some other process 
— as, perhaps, a misdirected compensatory hypertrophy. 

To be strictly sincere, it does not appear to me that it is a 
matter of very great importance under which of these two theories 
we enlist our intellect; for it is, after all, a question of purely 
academic interest, and for practical surgeons will remain such, 
until some happy discovery shall reveal the true cause of tumor 
formation in general, or detect why at a certain age the bodily 
powers begin to fail and the tissues to become sclerotic. 

The discussion of the causes has, I think, been much confused 
by the neglect of writers to keep these two main varieties of 
enlargement distinct. Guyon's school appears to have confined 
its observations to the fibrous class, teaching that prostatic en- 
largement was caused by, or was a part of, the fibrous changes 
incident to age ; while it is evident that Velpeau and his followers 
fixed their attention exclusively on cases of what I have called 
the first class, which is, in fact, the larger. Those accepting 
their views look for an explanation of prostatic overgrowth to 
the theory of tumor formation in general — tumors having been 
formerly defined as discontinuous purposeless hypertrophies of 
no known cause. Were Harrison's theory, which may be classed 
in the second category, correct, a cure might be hoped for, in 
cases not too far advanced, from ventrosuspension of the bladder. 
Such a form of treatment has actually been recommended by 
Goldman [95], who quotes Perassi and Krynski as favouring it. 

Size and Direction of Growth. 

Any prostate weighing more than six drachms (twenty-three 
grammes) may be considered abnormal. From this size they 
range up to twelve ounces (three hundred and seventy-three 



54 Pathology. 



PLATE XXXIII. 

The patient, D. D., aged fifty-eight years, was admitted to the German 
Hospital May 4, 1903. His bowels were regular; he has used alcohol and 
tobacco moderately. He complains of a burning sensation after urination. 
About one month before admission he had evidently suffered from an attack 
of acute cystitis, being compelled to urinate every ten minutes, and passing 
only 10 to 15 cc. (2 to 3 drachms) at a time. His urine was highly coloured, 
red, supposed to be bloody. His pain was more marked on moving about. 
Formerly he was forced to urinate every twenty minutes during the night; of 
late he has not urinated so often, usually three or four times in a night. The 
pain starts just above the symphysis pubis and shoots down the penis; there is 
also a stinging sensation at the end of the penis. 

The operation of suprapubic prostatectomy was performed, and a vesical 
calculus removed at the same time. Recovery was prompt, and the patient 
was discharged, entirely relieved of his urinary symptoms, June 3, 1903. 

The prostate, No. 1469, which is small and fibrous in character, is shown 
in the accompanying Plate. 



PLATE XXXIII. 




,. 



View of ax Enlarged Prostate (Xo. 1469), Measuring 2 X 1.5 X 1 cm. (f X | 
X h Inch). A Catheter has been Introduced through the Urethra. 



PLATE XXXIV, 





View of an Enlarged Prostate (No. 1555), Measuring 6 X 4.5 X 3 cm. (2! X if X i; 



Inches) and Weighing 52 Grammes (if Ounces). 

DUCED THROUGH THE URETHRA. 



A Catheter has been Intro- 



Size and Direction of Growth. 55 



PLATE XXXIV. 

The patient, J. M. C, aged sixty-three years, was admitted to the German 
Hospital July 18, 1903. He has used alcohol moderately; tobacco to excess. 
Six months before admission he first noticed difficulty in starting the stream, 
especially in the morning. As a rule, he was compelled to urinate only once 
during the night, and during the day he passed urine about four or five times. 
He stated that the amount passed was scanty, and that he had slight pain on 
starting the stream. One week before admission he had his first attack of 
retention, caused by exposure to cold and rain. He was relieved by catheteri- 
zation, and has had subsequently to be catheterized twice a day. 

On admission the amount of residual urine was found to be 60 cc. (2 
ounces). Rectal examination revealed a hard mass at the neck of the bladder, 
about the size of a large hen's egg. 

Operation (suprapubic prostatectomy) was undertaken a couple of days 
later. Recovery was uneventful, and the patient was discharged August 14, 
1903, entirely relieved of his urinary symptoms. 

The prostate, No. 1555, which is shown in the accompanying Plate, is a 
good example of the moderately firm fibrous type of enlargement. Its weight 
was 52 grammes (if ounces). 



56 Pathology. 



plate xxxv. 

The patient, T. C, aged seventy-seven years, was admitted to the German 
Hospital September 19, 1903. He had been suffering from frequency of uri- 
nation for years, the calls being more marked at night. Ten days before ad- 
mission urination became extremely difficult, and three days previously it had 
become impossible. For two days he had been catheterized by his family 
physician, but on the third day it became impossible to introduce the catheter. 

On admission the bladder was found to be greatly distended, reaching to 
the umbilicus. A prostatic catheter was passed, several strictures being en- 
countered anteriorly; while in the prostatic urethra there was detected a large 
false passage, leading to the left. The prostate was greatly hypertrophied, the 
size of a small orange. The urine obtained by catheterization was very bloody. 
After treatment by intermittent catheterization for two days, on September 21, 
1903, an English catheter was passed, and permanently retained. 

Operation (suprapubic prostatectomy) was undertaken September 23, 
1903. The patient never rallied, and died from shock and suppression of urine 
within a few hours. 

The prostate, No. 1623, which is shown in the accompanying Plates, 
weighed 122 grammes (4 ounces), and is a good example of cystic enlargement. 
See Plate xlvii (facing p. 67). 



PLATE XXXV. 




View of ax Enlarged Prostate (No. 1623), Measuring 7 X 6.5 X 5 cm. (2! X 2§ 

X 2 Inches) and Weighing 122 Grammes 14 Ounces). A Catheter has been 
Introduced through the Urethra. 



PLATE XXXVI. 




' X 



X 



o $ 



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So 


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w ^* 


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Size and Direction of Growth. 57 

grammes) or over in weight. Freyer [90] has removed one 
weighing fourteen and a half ounces. He has also removed pros- 
tates weighing ten and a half, and ten and a quarter ounces, 
respectively, with perfect functional result. The measurements 
of this last gland were five and a half inches antero-posteriorly, 
and three and a half inches transversely. The average weight 
of prostates removed at operation is probably not over three 
ounces; and the dimensions rarely exceed two inches trans- 
versely or three in the antero-posterior diameter. The greater 
the amount of fibrous tissue present, the less the size of the 
organ, other things being equal, and the greater the relative 
weight. The average weight of forty adenomatous prostates I 
find was 3! ounces; and of ten fibrous prostates the average 
weight was 2 ounces. 

Hence it is seen that the greatest enlargement takes place, as 
a rule, in an antero-posterior direction. The lateral lobes are 
not usually equally enlarged, but neither one is found to be con- 
stantly larger than the other. In the majority of instances no 
marked enlargement of the so-called median lobe exists. That 
this statement is contradicted by the greater number of museum 
preparations, is of no weight when we consider the great passion 
all surgeons may be said to have for preserving curious speci- 
mens; thus four or five prostates without a median projection 
may be discarded for the one possessing such an anomaly, which 
is preserved. It is very probable, moreover, that the number 
of patients with median projections who are operated upon is 
greater than the real ratio of occurrence of such lesion ; for where 
no such obstruction exists, and where residual urine is caused 
only by transverse obliteration of the urethra, easily overcome by 
catheterization, the patient is not so liable to be submitted to 
an operation. 

When a median projection into the floor of the bladder just 
posterior to the urethra does occur, it is probably safe to say 
that its origin may be traced to one or other of the lateral lobes. 



58 Pathology. 



PLATE XXXVII. 

The patient, S. L. T., aged seventy-three years, was admitted to the Ger- 
man Hospital July 9, 1903. He states that he has never used alcohol. He 
had an attack of gonorrhoea when about eighteen years of age. His present 
illness began two and a half years before admission, with frequency of urina- 
tion, especially at night; he was obliged to get up every fifteen or twenty 
minutes to urinate; and often when upon his feet he would pass his urine 
involuntarily. The flow lacked force, coming in a thin stream. Lately 
bright blood was present at times. At the beginning of this illness much 
sediment was passed in the urine. 

Examination on admission showed an enlarged prostate, very firm, the 
size of a lemon. 

Suprapubic prostatectomy was performed July n, 1903. Owing to his 
advanced age the patient did not react very well, but failed gradually, and died 
in a uraemic state on July 26, more than two weeks after the operation. 

The prostate, No. 1542, which is shown in the accompanying Plates, is an 
excellent example of the mixed type of enlargement, being partly glandular 
(Plate xl viii, facing page 68), and in places extremely fibrous (Plate xlix, 
facing page 69). 



PLATE XXXVII. 




View of the Upper Surface of an Enlarged Prostate (Xo. 1542), Measuring 
7X6x6 cm. (2f X 2\ X 2 h Inches) and Weighing 120 Grammes (4 Ounces). 
A Catheter has been Introduced through the Urethra. 



PLATE XXXVIII, 




View of the Under Surface of an Enlarged Prostate (No. 1542), Measuring 
7X6x6 cm. (2§ X 2\ X 2h Inches) and Weighing 120 Grammes (4 Ounces). 
A Catheter has been Introduced through the Urethra. 



PLATE XXXIX, 




A 
< 

W 

W 

u . 

£ < 

i-i « 

x§ 
x« 



vo 



w 

xS 

< W 

51 s 



5? W 



O 

IS 






PLATE XL. 




Enlarged Prostate (No. 1502), Measuring 6X6X5 cm. (2$ X 2§ X 2 Inches) 
and Weighing 100 Grammes (3 J Ounces). 



Size and Direction of Growth. 59 



PLATE XL. 

The patient, H. M. Y., aged sixty-six years, was admitted to the German 
Hospital June 8, 1903. The patient's father had died of prostatic disease. 
The patient had always been a moderate user of alcohol. For the past fifteen 
years he had suffered from frequency of urination, which was most marked at 
night. Two years before admission he had developed an acute attack of 
cystitis. In July, 1902, he had been operated upon for vesical calculus, since 
which time he had had a suprapubic fistula. He has not passed urine through 
the urethra for six months. 

Rectal examination on admission showed a very hard prostate, about the 
size of a lemon. 

Suprapubic prostatectomy was done June 15, 1903; a stone the size of a 
lima bean was extracted from the bladder, and the prostate removed entire 
along with the prostatic urethra. Recovery was rather tedious, but the pa- 
tient was discharged August 1, 1903, in good health, and with no urinary 
trouble. 

The prostate, No. 1502, which is shown in the accompanying Plate, was 
the seat of considerable catarrhal and interstitial inflammation, as seen by 
the microscopical section, Plate xlv (facing p. 65). Its weight was 100 
grammes (3 J ounces). 



6o Pathology. 



PLATE XLI. 

The patient, W. T. D., aged seventy-three years, lawyer by occupation, 
was admitted to the German Hospital December 3, 1904. He had always 
used alcohol and tobacco in moderation. He had had the ordinary diseases 
of childhood, and had had enteric fever twice, in 1862 and 1863. Since that 
time he has always enjoyed good health. 

For a little more than three years he has had slightly more frequent desire 
to urinate, with occasional imperative urination. Three years ago, after slight 
alcoholism, there developed acute retention of urine, which was relieved by the 
catheter. For a week subsequently a catheter had to be passed twice daily, 
and since this time the patient has had to be catheterized on the average of 
once in a week or ten days, sometimes only every two weeks; never with any 
degree of regularity. The chief indication for catheterization was pain; a 
considerable amount of urine would usually be drawn, and the patient would 
urinate generally about five times during the night following these catheteriza- 
tions, though there would be times when he would not get up at all. 

On admission there was found to be residual urine amounting to 60 cc. 
(2 ounces). 

Suprapubic prostatectomy was done December 8, 1904. On opening the 
bladder it was found that the prostate was markedly enlarged, especially upon 
the right side, which equaled a lemon in size. On attempting to enucleate the 
whole gland the tip of the much enlarged right lobe broke off from the body of 
the enlarged organ, and lay free in the bladder. It was removed, and the re- 
maining portions of the prostate were then enucleated in one piece. Unin- 
terrupted recovery followed, and the patient is completely relieved of his 
urinary symptoms. 

The prostate, No. 2138, which is shown in the accompanying Plates, 
weighed 162 grammes (5 J ounces). 



PLATE XLI. 




View of an Enlarged Prostate (No. 2138) Weighing 162 Grammes (5J Ounces). 
Very Marked Enlargement of the Right Lobe. 



PLATE XLII, 





t wfw^ T ^' ME PROSTATE (X °- 2I - 8) SH ° WN » P ^TE XLI 

(a) (6) the right lobe, (b) the intravesical portion. (c) The left lobe 



PLATE XLIII. 







II 



View of the Upper Surface of an Enlarged Prostate (No. 1826) Weighing 56 
Grammes. A Catheter has been Introduced through the Urethra. 



Size and Direction of Growth. 61 



PLATE XLIII. 

The patient, A. S., aged sixty-eight years, was admitted to the German 
Hospital March 25, 1904. He had always enjoyed good health, and had lived 
a very active life. For fourteen months previous to his admission he had had 
frequency of urination, and at times had been forced to use a catheter every 
fifteen minutes. For the last three months he had been confined to bed with 
a catheter constantly in the bladder. He likewise suffered from diabetes. 
His general condition, however, improved so much after the institution of con- 
tinuous drainage, that an operation was deemed justifiable. 

Suprapubic prostatectomy was accordingly performed on March 26, 
1904. The operation proved to be perfectly successful. Urine was volun- 
tarily passed through the urethra first on April 6, and the patient was soon 
afterwards discharged with the suprapubic wound firmly healed, and with his 
urinary functions in normal condition. 

The prostate, No. 1826, is shown in the accompanying Plate. It weighed 
56 grammes (nearly two ounces), and is a good example of irregular enlarge- 
ment, the projection of the so-called middle lobe making the under surface of 
the gland nearly clover-leaf in shape. 



62 Pathology. 

In the immense majority of cases carefully examined in recent 
years, demonstration of such origin has been possible, the pedun- 
culated growth being attached to a lateral lobe much as a sub- 
peritoneal fibroid is attached to the uterus. It seems, indeed, 
not impossible that, in those cases where it has been said that 
no such attachment existed, the growth had finally torn its pedicle 
loose, and that it might in time even have migrated, as is not 
unfrequently the case with the somewhat analogous tumors of 
the uterus. 

There is, however, another condition, well described as the 
formation of a lip at the vesical orifice of the urethra, which is 
sometimes mistaken for a median outgrowth. This lip in reality 
is formed by the enlargement of accessory prostatic glands situated 
beneath the vesical mucous membrane, and within the limits 
of the internal sphincter of the bladder. Where an adenomatous 
mass springing from one lateral lobe projects beneath the mucous 
membrane in this situation, the internal vesical sphincter is not 
separated from the bladder by the growth, which merely pushes 
this sphincter before it. But in the process known as the lip 
formation, which has been especially studied by Ciechanowski 
[49], the adenomatous mass is found between the vesical mucous 
membrane and the sphincter, and may in time, by over-stretching 
this latter structure, keep the prostatic urethra constantly patu- 
lous, and urinary incontinence may even ensue. Such a process 
as this may exist without any involvement of the prostate gland 
itself. Residual urine may form in a pouch behind this posterior 
urethral lip, and indeed all the subjective symptoms of prostatic 
enlargement may harass the patient. I am persuaded that this 
is an unusual condition, and it seems to me that some writers 
make it unduly prominent. 

Physical Characters. 

When we come to a consideration of the physical characters 
of the enlarged prostate other than its size and weight, we find 



PLATE XLIV. 




View of the Under Surface of an Enlarged Prostate (No. 1826) Weighing 56 
Grammes. A Catheter has been Introduced through the Urethra. 



Physical Characters. 63 

that the most important from a therapeutic point of view is its 
density. This varies from that of cartilaginous hardness, such 
that the knife creaks as it cleaves the tissue, to a glandular soft- 
ness which may perhaps best be compared to a wet sponge of 
close texture. The former characteristic, hardness, is found 
exclusively in prostates which contain much fibrous tissue, and 
which I have placed in the second class ; while the softer the organ 
is found to be, the more surely may it be considered to belong 
to the adenomatous group of cases. Between these two extremes 
all grades of density exist; but few indeed are the cases where 
it is impossible to class the gland readily in one or the other 
category. 

The rate of growth is variable both of the gland as a whole, 
and of its individual parts. The soft glandular prostates grow 
with greatest rapidity, and may furnish evidence of increase in 
size to the palpating finger within a period of a few months. 
Extremely rapid growth occurs only in neoplasms. The fibrous 
prostate grows slowly, and, as already remarked, rarely equals 
the glandular in size. Some authors have even contended for 
a progressive decrease in size occurring in this form, constituting 
true prostatic atrophy; but their views have not met with un- 
reserved acceptance. In the fibrous variety, moreover, it is un- 
usual to find pedunculated or sessile growths projecting from 
the surface of the prostate, these so-called prostatic tumors oc- 
curring almost without exception where the organ has under- 
gone a glandular overgrowth. 

These " prostatic tumors" are quite characteristic. In the 
prostate have been found at times true tumors, myomata, adeno- 
mata, and other growths; but what is understood by a prostatic 
tumor is a localized overgrowth of glandular acini, without in- 
crease in the number of the corresponding ducts. This acinous 
overgrowth compresses the surrounding stroma into a capsular 
envelope, which it has been customary to regard as a myomatous 
growth, the prostatic tumors being denominated adenomyomata. 



64 Pathology. 

Later investigations, however, have shown that this capsule is 
in reality composed of new connective-tissue elements, or fibro- 
blasts, while the muscle tissue probably does not increase in 
quantity. In time the stroma surrounding these localized glan- 
dular outgrowths itself begins to grow, and may eventually, accord- 
ing to Moullin [176], compress the pre-existent acini, so that the 
prostatic tumor formerly almost wholly glandular in character 
becomes eventually fibrous and solid. Moullin claims that in- 
crease in size, though less rapid, still continues during this which 
he calls the second stage of the pathological process. Whether 
or not we accept this view, that the fibrous is a subsequent stage 
of the glandular change, it is certain that the prostatic tumors, 
no matter what their state, are under considerable pressure from 
the surrounding stroma, and that they tend to grow in the direc- 
tion of least resistance. This latter fact frequently causes them 
to project beneath the mucous membrane of the bladder, pos- 
terior to the urethral orifice. When seated within the substance 
of the gland, they are prone to start out of it on section, and 
may readily be enucleated with the finger, the few ducts from 
which the numerous new acini spring, unless they are included 
in the section, serving as their pedicle of attachment to the rest 
of the organ. 

In some cases no such prostatic tumors are found, the gland 
presenting a nearly uniform, general enlargement, either glandular 
or fibrous in character; or a general glandular enlargement 
may exist in some areas, and a general fibrous enlargement in 
others. When this is the case, no nodulation of the surface 
occurs, and there can be, of course, no " median lobe" present. 

When a large part of the prostate becomes intravesical, it is 
usual to observe a constriction between this and the extravesical 
portion. This constriction is produced by the edges of the pros- 
tatic sheath, which as Mr. Freyer [90] says, has been shouldered 
aside by the prostate in its efforts to expand beneath the mucous 
membrane of the bladder. 



PLATE XLV. 




A Section from Prostate No. 1502 (See Plate XL) showing Considerable 
Hyperplasia and Some Dilatation of the Glandular Structures. 
For the most part the lining epithelial cells are disposed in a single layer, but here 
and there there are two or more layers, which, together with the mucoid infiltration of 
the cells and the periacinar round-cell infiltration, indicate catarrhal and other inflam- 
matory alterations. ( X 250.) 



Microscopy. 65 

Pathological Histology. 

Our knowledge of the pathological histology of the enlarged 
prostate is due almost entirely to the monumental and exhaustive 
work of Ciechanowski [49,50], supplemented by the researches of 
Albarran and Halle [3], of Motz [172 a], of Greene and Brooks 
[102], of Crandon [54], of Daniel [56 a], and of Herring [120a]. 
Ciechanowski' s original article was published in 1896 in Polish, 
and hence did not find a very large circle of readers. It was re- 
published in German in 1900, after being in the editor's hands for 
nearly two years; but it was only on the appearance of an 
article from his pen in French in 1901, that his views became 
widely known and thoroughly appreciated. 

His studies fall into two groups, in the first of which he dis- 
cusses the changes occurring in the bladder as the result of old 
age, of prostatic obstruction, and of chronic cystitis; the second 
division being devoted to a consideration of the prostate itself. 

By careful and repeated microscopical measurements he 
showed that vesical insufficiency occurred from a diminution in 
the amount of muscular tissue in the bladder walls. He detected 
no increase in the connective tissue except where chronic cystitis 
was present. This is in accord w T ith the clinical observation of 
Guyon [108], who noted that if no cystitis was present the residual 
urine gradually accumulated without producing many symptoms, 
until the bladder might be distended to above the umbilicus, 
before overflow from retention occurred; whereas if infection 
was present frequent urination arose early in the case, and 
the bladder did not dilate, but became thickened and con- 
tracted. 

Ciechanowski held, and Greene and Brooks as well as Cran- 
don, who each undertook a separate examination of his conclu- 
sions, agree with him, that both the glandular and the fibrous 
overgrowths of the prostate are the long-delayed result of a chronic 
inflammation, insidious in onset, slow in course, and for many 
years perhaps entirely latent. The process of overgrowth Cie- 

6P 



66 Pathology. 

chanowski thinks may be observed to occur simultaneously in 
both the glandular and the stromal portions of the prostate. 

The description given in the following pages is freely borrowed 
from the authors above mentioned, and to their works I here 
desire to express my indebtedness. 

Examination of a microscopical field from an enlarged prostate 
shows most noticeably, as a rule, increase in glandular structure. 
Some have thought that new acini were formed, as in the case 
of the true adenomata observed in the mammary gland, where 
the chief pathological change evident is the preponderance of 
glandular tissue over the normally present fibrous reticulum; 
but in the prostate the process does not appear to be one of true 
tumor formation, since it seems certain that these extra gland 
acini are merely dilated gland tubules which, though previously 
present, were then insignificant in size. Study of the mucous 
membrane lining these gland spaces shows a variety of changes 
present. The cells may exist in only the usual single layer, or 
they may be heaped up into several layers, showing a catarrhal 
inflammation in which new cell formation has taken the place 
of secretion. In this way the acini may become closely packed 
with epithelial cells, simulating on hasty examination cancer 
nests. Albarran and Halle [3] observed epithelial prolifera- 
tion such as this in fourteen out of one hundred cases examined, 
and classed them all as commencing carcinomatous degenera- 
tion. But as pointed out by Greene and Brooks [102], such a 
large percentage would be unheard of, and contrary to all clinical 
evidence. Moreover, these authors found such acini in many 
of their own cases which were undoubtedly not cancerous; so 
it seems safe to conclude that a carcinomatous change cannot 
be diagnosticated unless epithelial cells can be found displaced 
from the alveoli and proliferating in the stroma. This condition 
was also observed by Albarran and Halle [3], some of whose 
cases were undoubtedly instances of carcinoma; and while we 
must reject their former conclusions as erroneous, we must yet 



PLATE XLVI. 




^:%aM 



A Section from Prostate No. 1258 showing Marked Glandular Hyperplasia 
(Photomicrograph, x 280.) 



PLATE XLVII. 







Wk 









e.\\ N '« 



#3 









^ 



1 



&J&; 



*?» 






MA 









A Section from Prostate Xo. 1623 (See Plates XXXY, XXXYI) showing Cystic 
Dilatation of the Acixi with Consequent Flattening and Atrophy of the 
Lining Epithelium. (X 180.) 



Microscopy. 67 

be grateful to them for calling our attention to the not very re- 
mote possibility of malignant change. 

In some cases the acini will not be completely filled with 
epithelial cells, but there will be such an admixture of lymph- 
ocytes, and even of polymorphonuclear leukocytes, as to constitute 
true suppuration; the prostate in these cases being riddled with 
minute abscesses, although outwardly presenting only the usual 
evidences of senile enlargement. 

If secretion takes the place of cell proliferation, the single 
layer of columnar cells will still surround the acinus, but this 
will be dilated by a variable amount of mucoid material, very 
probably containing one or more concretions. In some instances 
extreme dilatation of a few of the acini is present, and the well- 
known though rather rare cystic prostate is produced. In some 
of these cases the epithelial lining is squeezed out of existence 
entirely, and the cyst is surrounded only by stroma. The cells 
may at times be seen lying in rows detached from the acinous 
wall, free in its cavity. Sometimes two neighbouring acini are 
seen with only a thin partition between them; and it is easy to con- 
ceive how the coalescence of two or more such acini might occur. 

Turning our attention now to the ducts, we find that these are, 
as a rule, compressed in direct proportion to the dilatation of the 
acini. In some places a duct will be seen with its opposed mucous 
linings flattened by pressure; and other ducts may be found 
which have become converted into fibrous bands, with no trace 
of epithelial structure remaining. It is to be noted that the pros- 
tatic concretions have never been observed to plug the ducts; 
these seem to be always compressed by an outside influence. 
Yet Daniel [56a] was "struck by the frequency with which the 
ducts are obstructed by lecithin or amyloid bodies, desquamated 
epithelium, or pus cells." 

This process of proliferation in the acini, and compression of 
the ducts, leads in many instances to the formation of the " pros- 
tatic tumors," or pseudo-adenomata, previously discussed. But 



68 Pathology. 

for an explanation of this process we must advance our obser- 
vations from the glandular structure and consider the changes 
found in the stroma. 

One of the first things to meet the eye as it studies the stroma 
is the collection here and there of groups of small round cells — 
true round-celled infiltrations, according to Ciechanowski [49] 
and others. These aggregations of cells are not regarded by 
Crandon [54] as at all the same as the lymph nodes described 
by Walker [235] as occurring in the normal prostate. They are 
most frequent beneath the mucous membrane of the urethra, 
then in patches along the excretory ducts ; but are also sometimes 
observed surrounding the terminal alveoli. These round-celled 
infiltrations are here, as elsewhere, significant of inflammation, 
and indicate a rather acute process in their immediate locality. 
But in the enlarged prostate they are seldom observed in large 
areas, or very uniformly distributed. They seem rather to be 
aggregated in a few spots for some recent local inflammation. 

The stroma surrounding the ducts, and that immediately 
about the acini, shows the presence of true fibroblasts, the same 
that are seen in areas formerly inflamed, but becoming cicatricial. 
And in other spots of the stroma may be seen fully formed fibrous 
tissue — true cicatrices — where the contracting fibroblasts have 
perhaps compressed and even obliterated one of the excretory 
ducts or an acinus. Evidence of this last event is found in the 
occasional existence of a prostatic concretion in the midst of scar 
tissue, this concretion having naturally resisted the obliteration 
which its containing acinus suffered. The muscle cells are not 
found to be hypertrophied. What were formerly considered 
muscle cells are now recognized as the fibroblasts. But it is 
not impossible, when an acinus first begins to dilate, that for a 
short time its immediately surrounding muscle cells may hyper- 
trophy, and endeavour to evacuate the contents of the retention 
cyst forming within their embrace. But any such hypertrophy, 
if it ever exists, is very soon overcome by the fibrous growth. 



PLATE XLVIII 







\» ; vsfe£ , 



A Section, from Prostate No. 1542 (See Plates XXXVII, XXXVIII and XXXIX), 
showing Considerable Glandular Hyperplasia Adjacent to Much Con- 
nective Tissue Overgrowth, and Two Corpora Amylacea. 
The connective tissue hyperplasia was more marked in other portions of the speci- 
men (Plate XLIX), and throughout the specimen there was a moderate amount of round- 
cell infiltration, especially about the blood-vessels. (X 180.) 



PLATE XLIX. 









'. St} •'■'.-> \ 




A Section from Prostate No. 1542 (See Plates XXXVII, XXXVIII, and XXXIX), 
showing Marked Connective Tissue Hyperplasia with Considerable Atrophy 
and More or Less Complete Obliteration of the Acini. 
In another portion (Plate XLVIII) there was considerable glandular hyperplasia, 

and throughout the specimen there was a moderate amount of round-cell infiltration, 

especially about the blood-vessels. ( X 100.) 



Microscopy. 69 

The particular form of the enlargement found depends en- 
tirely for its glandular or fibrous character on the situation of 
the intraglandular and interglandular changes, and on their 
relation to each other. 

If the intraglandular changes occur most markedly in the 
periphery of the gland, that is to say, away from the ducts, while 
the interglandular or stromal changes arise chiefly in the interior 
of the gland, around the prostatic ducts and about the urethra, 
then the character of the enlargement is adenomatous, since the 
ducts are obstructed, and the acini undergo cell-proliferation or 
cyst formation. 

But if the periglandular changes are most marked in the per- 
iphery, then the acini are compressed, perhaps obliterated, by the 
surrounding growth, and the ducts are all that remain of the glan- 
dular structure of the prostate, which may then be a mere mass 
of scar tissue. If the scar tissue continues of the embryonic 
type, consisting largely of fibroblasts, the prostate will enlarge, 
though very slowly ; but if true fibrous tissue forms, it is probable 
that a decrease in size will occur. 

As remarked before, it does not seem to me at all likely that 
one of these processes succeeds upon the other. It appears to 
me far more rational to suppose that an enlargement which has 
commenced by constriction of ducts and dilatation of acini, will 
continue as such for all time, or until a prostate the size of a 
cocoanut has been produced; and that a process in which the 
gland acini are compressed and obliterated by fibrous tissue which 
is more marked in the periphery than in the centre of the prostate, 
has been such from the beginning; not that the large adeno- 
matous structure subsequently became fibrous. 

The fibrous form is generally admitted to be distinctly rarer 
than the adenomatous, but Greene and Brooks [102] found it to 
preponderate in the specimens, fifty-eight in number, examined 
by them. 



7° Pathology. 

These authors describe the clinical course of the disease in 
the following terms: 

Suppose, for instance, that acute inflammation of the prostate 
arises. "With a cessation of acute inflammation following a 
removal of its cause and normal reaction on the part of the 
tissues of the organism, interstitial hyperplasia should cease, and 
retraction and atrophy follow from sclerosis of the fibers, as the 
embryonic tissue takes on adult form. Such a result does follow 
in favorable cases of prostatitis in the young and healthy, and, 
as the sclerosis of the newly formed tissue continues, the atrophic 
or small hard prostate follows to a greater or less extent, always 
provided, however, that this same fibrous sclerosis does not excite 
secondary changes in the glandular epithelium. But in the 
middle-aged or old man, particularly where more or less general 
or arterial disease exists, resolution and healing do not so readily 
follow, and instead of cessation of connective-tissue hyperplasia 
the condition becomes chronic. With the increased fibrosis, con- 
sequent thickening of the walls of the veins and lymphatics fol- 
lows, and chronic congestion is added to the factors tending to 
prolong and increase interstitial hyperplasia, edema and inflam- 
matory exudation. So it happens that in the enlarged prostate 
of the aged, acute and subacute proliferations are found mingled 
with the thickened masses of adult sclerosed connective tissue. 
As an inevitable result of this overgrowth of stroma, atrophy of 
the smooth muscle cells follows. This may be of greater or less 
degree, greater if the inflammation partakes more of the acute 
type where parenchymatous degenerations are most rapid, less 
if the process be more chronic. ,, 

Thus by a fibrous overgrowth alone, continuing for months 
or years, the prostate may be considerably increased in size; 
but when the glandular changes are concerned as well, quite 
rapid enlargement may occur. Greene and Brooks [102], who, 
it will be remembered, found the fibrous type of enlargement more 
frequent in their specimens, seem to incline to the opinion that 



/Etiology. 71 

it is the primary change, and that epithelial or glandular pro- 
liferation is produced by it. Their views, however, are not very 
clearly expressed. 

Whether these recent views as to the invariably inflammatory 
origin of prostatic enlargement will be hereafter disproved, re- 
mains to be seen. It is at present the easiest solution of a vexed 
question; but I am not sanguine as to its being final. 

Two things seem to me to need emphasis: the first, that the 
truly adenomatous origin of the glandular form does not appear 
to have been disproved ; and, secondly, the very great importance 
of chronic passive congestion, or call it chronic inflammation if 
you will, in the production of the fibrous form of prostatic 
enlargement. 



CHAPTER IV. 

CLINICAL PATHOLOGY: EFFECTS ON URETHRA, BLADDER, 
KIDNEYS, URINE, AND RECTUM. 

As the prostate gland enlarges, whether from tumor formation 
or as the result of a general hyperplastic process, various changes 
are produced in the urethra, the bladder, and the rectum; and 
less directly on the urine, the kidneys, and the general health. 

Effects on Urethra. 

The length of the urethra is probably always increased. Its 
normal length averages eight inches (20 centimetres), according 
to the extensive statistics compiled in 1898 by Keyes [132]; but 
it varies from six to ten inches in health, and thus a length of over 
eight inches may be no longer than normal for any individual 
patient ; while, on the other hand, the urethra may be abnormally 
long by two inches when its length merely reaches the average. 
In drawing conclusions from such measurements the patient's 
height, his age, and the length of his penis, should all be borne 
in mind. The urethra is generally considered to increase slightly 
in length with advancing years, apart from any pathological 
change; and, other things being equal, the taller the patient, 
and the longer his penis, the greater may be expected to be the 
length of his urethra. The length of the penis, however, and 
consequently that of the urethra, varies so much in the same 
individual, according to the local temperature and nervous emo- 
tions on being examined, that this increase, unless marked, and 
accompanied by other symptoms, cannot be regarded as of very 
great importance. One more point in this connection should be 

borne in mind; that is, that when the bladder is full, and the 

72 



PLATE L. 




Elevation of Vesical Orifice of the Urethra and Formation of a Retro- 

prostatic Pouch. 
Note the increased curve and length of the subpubic urethra. Compare with Plate _XII. 



PLATE LI. 




Lateral Deviation of the Urethra Towards the Patient's Right, Due to 
Overgrowth of the Left Lobe of the Prostate. — (After Anger.) 



Effects on Urethra. 73 

desire to urinate is present, the prostatic urethra, unless retention 
occurs, becomes physiologically part of the bladder; and the 
urine is withheld from the bulbous urethra only by the voluntary 
muscles surrounding the membranous portion of this canal. 
Hence it will be found that if a catheter is passed into the blad- 
der to draw off residual urine, or urine which there is no desire 
to evacuate, the whole length of the urethra, including the prostatic 
portion, will be traversed before any urine flows; whereas if 
desire is present, and the prostatic urethra is in physiological 
continuity with the bladder, a corresponding length of catheter 
will be subtracted from the total length formerly required. 

The length as measured will also be greater in a curved than 
in a straight instrument. 

In some of these cases the length of the urethra may be in- 
creased up to fourteen or sixteen inches; so that where urinary 
retention is evident the surgeon must not be discouraged on fail- 
ing to reach the bladder with the ordinary length of catheter. 

This increase of length occurs chiefly in the prostatic portion, 
which may measure as much as four inches. The bulbous 
urethra is also lengthened. 

The means by which this increase in length is brought to pass 
may be explained by the fixation of the prostate gland at its apex, 
and the necessity which therefore exists for any enlargement to 
take place in a posterior direction. As will be remembered, in 
speaking of the relational anatomy of the prostate, attention was 
called to the greater firmness of its attachment to the rectum, as 
compared with its superior relations; hence its greater enlarge- 
ment is usually found extending into the floor of the bladder, 
this being a more compressible viscus than the rectum, which is 
so often filled with solid faecal matter, while the fluid contents 
of the bladder offer little resistance to prostatic encroachment. 
The enlargement upward of the prostate explains how in the en- 
larged organ the prostatic utricle comes to occupy the lower part 
of the prostatic urethra instead of its centre. 



74 Clinical Pathology. 

The fact that the neck of the bladder is thus encroached 
upon brings about a second change in the urethra, and this is 
in its direction. The vesical orifice of the urethra is thus raised 
from its normal situation, even where no isolated median enlarge- 
ment exists; and the vesical half of the prostatic urethra may 
in extreme cases assume a right angle with its outer portion, so 
that the curve of the ordinary metal or English catheter will not 
fit the prostatic urethra, its point impinging upon the posterior 
wall. Besides a change in direction in the sagittal plane thus 
produced, there may be a lateral deviation of the urethra, due to 
unequal enlargement of the two lateral lobes, the channel being 
deflected towards the less enlarged lobe. Hence in passing a 
metal catheter in cases of obstruction from enlarged prostate, if 
the beak of the instrument cannot be made to ride over the ob- 
struction by depressing its handle, the surgeon should turn it first 
to one and then to the other side. If a pedunculated enlarge- 
ment exists just back of the vesical orifice, a Y-shaped channel 
may be present, and the catheter will pass to either side of the 
median line. 

By the same process by which the vesical orifice of the urethra 
is raised, the posterior or inferior wall of the prostatic urethra 
is much lengthened; and if no corresponding growth occurs in 
that portion of the prostate anterior to the urethra, and the an- 
terior wall of the prostatic urethra remains unchanged, the diam- 
eter and consequently the capacity of the prostatic urethra may 
be much increased, so that it may hold an ounce or two of urine. 
Such extreme enlargement is, of course, rare; indeed, it more 
often happens that this portion of the canal is more or less com- 
pressed by the centripetal enlargement of the lateral lobes, so 
that on transverse section it appears as a vertical chink, instead 
of the normal crescentic outline. If this lateral compression be 
marked, and it is more apt to be so in cases of fibrous overgrowth 
than in adenomatous enlargement, total retention of urine may 
ensue, even though the vesical orifice of the urethra be not dis- 



PLATE LII, 




Formation of a Y-shaped Channel due to Presence of a Pedunculated 

"Median Lobe." 

Several orifices of vesical pouches are also seen. A small concretion is attached to the 

"middle lobe." — (After Cruveilhier.) 



PLATE LIII. 




Overgrowth of Suburethral Portion of Prostate, Changing Subpubic Curve 
of Urethra. — (After Anger.) 



Effects on Urethra. 75 

placed, and the catheter enter with its usual facility; for while 
a catheter may easily overcome very considerable lateral com- 
pression, the bladder will be unable to effect a like dilatation of 
the canal by hydrostatic pressure applied only to its vesical ori- 
fice. Instead of retention of urine being produced by the de- 
formities of the urethra caused by enlargement of the prostate, 
true incontinence of urine — not merely retention with overflow 
— has occasionally been noted where the eccentric growth of 
the prostate keeps the urethral orifice constantly patulous. 

If the parts below the urethra enlarge with greater rapidity 
towards its floor than towards the vesical trigone, the normal 
curve of the subpubic urethra may be obliterated, the canal here 
becoming straight; or its convexity may even be directed for- 
wards, towards the pubic symphysis. In such cases the catheter 
must be reversed before it will enter the bladder. (Plate liii.) 

Vignard [234] has shown that among twenty-eight specimens 
which he examined, in sixteen obstruction to urine existed through- 
out the whole prostatic urethra; in nine cases the obstruction 
was chiefly at the vesical orifice, but also to some extent in the 
urethra; while in only three out of the whole twenty-eight cases 
did it exist at the vesical orifice alone. 

Besides the changes in length, direction, and size, to which 
the prostatic urethra is thus subject, it may be curiously distorted 
by submucous adenomata springing into its canal from any direc- 
tion, most frequently from beneath its floor. Failure to remove 
such masses, palpable neither from within the bladder nor from 
the perineum, is the probable explanation of persistence of symp- 
toms after many a prostatectomy. 

The large submucous veins of the prostatic urethra become 
much engorged along with all other neighbouring veins, and by 
a sudden access of congestion are the chief cause of attacks of 
acute retention of urine. They may bleed spontaneously at times, 
and even the most gentle catheterization may provoke consider- 
able haemorrhage. 



76 Clinical Pathology. 

Effects on the Bladder. 

Of all the changes produced in the bladder by enlargement 
of the prostate gland, none is of greater importance than the 
formation of a post-prostatic pouch, by the combined elevation 
of the urethral orifice and descent of the vesical floor. This is 
probably a much more frequent cause of residual urine than is 
the ball-valve action of a pedunculated submucous adenoma 
blocking the urethra. 

The descent of the vesical floor is the result, not the cause, 
as Mr. Harrison [116] maintained, of the enlarged prostate. 
Where obstruction exists to the evacuation of a hollow viscus, 
it is surely always the preceding change, and the dilatation which 
is found arises from vain efforts to expel the contents. A familiar 
example of this is seen in pyloric stenosis. If this obstruction 
be overcome, by gastroenterostomy or otherwise, the atonic stom- 
ach recovers its normal physiological action in the vast majority 
of instances. Similarly, if the urinary obstruction be removed, 
by excision or even by suprapubic drainage, the dilated and 
feeble bladder will recover, if the condition has been relieved 
in time. 

The prostatic obstruction throws increased work on the blad- 
der, as Mansell Moullin [176] has well said, and when it is no 
longer able to empty itself, the floor, which is the part last to be 
emptied as well as the weakest, is the first to dilate. When this 
stage has been reached, every effort of the bladder for evacuation 
only serves to press the urine against its floor and to increase 
the capacity of the post-prostatic pouch. 

The shape of the urethral outlet of the bladder may be vari- 
ously altered according to the part of the prostate most overgrown. 
It is usually crescentic in outline, the concavity of the cres- 
cent being directed towards the most enlarged part. But if the 
prostate enlarges nearly equally in both its supra-urethral and 
infra-urethral portions, a collar-like projection will occur into the 
bladder all around the urethral orifice. This form of enlargement 



PLATE LIV, 




Collar-like or "Cervix Uteri" Enlargement of Prostate, seenjfrom within 
the Bladder. — {After Socin and Burckhardt.) 



PLATE LV 




Enlargement of the Lateral Lobes of the Prostate forming between Them 
a Bar at the Neck of the Bladder. — (Watson.) 



Effects on Bladder. 77 

has been graphically compared, both in appearance and in feel, 
to the cervix of the uterus, the urethra being placed in the midst 
of a hillock, like the cervical canal between its lips. (Plates liv 
and lvi.) 

If the lateral lobes enlarge uniformly and tend to spread away 
from the middle line, they are apt to raise a fold of tissue taut 
across the vesical orifice of the urethra. This fold may be com- 
posed of mucous membrane alone, or may have a varying amount 
of submucous tissue in it as well. It is the most usual form of 
"bar at the neck of the bladder," and in many instances is a 
serious obstacle to catheterization. (Plate lv.) 

As has been already remarked, an isolated adenomatous 
mass, springing from the prostate beneath the neck of the blad- 
der just posterior to the urethral orifice, may cause the inner part 
of the urethra to become Y-shaped. (Plate lii.) 

Very great impairment of the urinary function may result 
when there is no apparent mechanical obstruction. In such 
cases the cause of the trouble is the existence of a hard oedema, 
or of an arteriosclerosis or fibrosis in the neck of the bladder 
and the prostate. Such processes, the result of long preceding 
congestions or chronic inflammations, render the normally soft 
and pliable vesical outlet firm and rigid, so that the prostatic 
urethra can no longer open up into practical continuity with the 
bladder during urination; and as a consequence, obstruction 
arises from the immobility of the parts. In such cases the pros- 
tate may be little or not at all enlarged, but extremely hard; 
thus furnishing a marked example of the fibrous class. 

While the most prominent changes in the bladder are thus 
seen to occur in the neighbourhood of its neck and the trigone, 
certain alterations throughout its walls occur in many cases, and 
these are of nearly equal importance. They are partly the re- 
sult of the efforts to overcome the obstruction, and partly the 
result of the chronic cystitis which almost invariably accompanies 
prostatic enlargement. 



78 Clinical Pathology. 

The increased work thrown on the bladder causes first an 
hypertrophy of its muscular walls. If the obstruction is not 
relieved in time, atony ensues, with dilatation of the bladder, 
or fibrous degeneration takes the place of the hypertrophy, and 
the bladder contracts. In cases where the obstruction is unre- 
lieved, chronic retention occurs, and the amount of residual urine 
gradually increases. The walls of the bladder may then become 
much distended and extremely thin; and its fundus may reach 
to the umbilicus or above, before partial relief occurs from over- 
flow. Atony of the bladder from actual disappearance of its 
muscular fibres through fatty degeneration may thus arise; and 
although atony so extreme as to be irremediable is no longer 
thought to be very frequent, yet the surgeon should bear this 
danger in mind, and see that his patients are relieved of their 
retention before matters have gone too far. 

But the bladder may not dilate; its walls may become much 
thickened, corrugated and pouched; its cavity may even con- 
tract, and contain only a few drachms of urine, necessitating its 
evacuation every ten or fifteen minutes. As the muscular walls 
become fibrous they contract on the contained mucous coat, and 
this may be seen bulging out in pouches in the interstices be- 
tween the thickened fibrous bands, as efforts to expel the urine 
are made. These herniated pouches may in time remain perma- 
nently, not disappearing even when the bladder is relaxed. In 
such cases not only may residual urine collect in these pouches, 
but calculi may form in them, and thus much increase the pain 
and discomfort of the patient. 

The changes in the bladder walls the result of cystitis differ 
in no respect from those due to cystitis from other causes. Vesical 
catarrh is a prominent symptom, and the viscid ropy mucus adds 
to the urinary obstruction. The mucous membrane is highly 
congested; it may be ulcerated in places; and calcareous deposits 
are frequently found on its surface. So turgid are the veins that 
it is the rule for some degree of hematuria to be developed as 
soon as the bladder is relieved of the urinary pressure. 



/ 



PLATE LVI. 





Atoxic, Dilated Bi.al.deb, from Enlargement of the Prostate without Marked 

Cystitis. 
(From a specimen in the Mutter Museum of the College of Physicians of Philadelphia.) 



Effects on Kidneys. 79 

Where infection is present, it is probable that chronic urinary 
retention so extreme as to produce overflow never occurs; but 
that the acute pain and frequency of urination claim the sur- 
geon's services at an earlier stage of the case. It is therefore 
in the infected cases that the small rugous and thickened bladders 
above referred to are oftenest encountered; and it may be con- 
sidered a question whether the infection causes the contraction 
primarily, or whether this occurs only because the high grade of 
cystitis present makes relief to obstruction imperative before 
dilatation of the bladder has taken place. 

Effects on the Kidneys and Ureters. 

From the presence of residual urine in any amount, changes 
may further be observed in the orifices of the ureters. Normally 
these tubes enter the bladder wall obliquely, passing through 
the vesical coats for one-quarter or one-third of an inch; and 
they discharge their contents into the bladder in driblets or in 
spurts at intervals of some seconds. But as the bladder becomes 
distended the ureteral openings are compressed, and the dis- 
charge of their contained urine becomes more difficult. When 
the bladder is excessively distended, and its wall is overstretched 
in all its parts, the ureteral orifices may become constantly patu- 
lous, by the approximation of their course through the bladder 
walls to a straight line. Dilatation of the ureters may result. 
(Plate lvtii.) 

As soon as the pressure in the ureters becomes increased, a 
damming up of urine occurs into the pelvis and calices of the 
kidneys; and this change in pressure, apart from any infection, 
is soon manifested in the behaviour of the kidneys themselves. 
Circulatory disturbances are produced in the kidneys, the im- 
mediate effects of which are not accurately known ; but from the 
observations of Cabot [41] it is evident that in their early stages 
they are not beyond the hope of cure. Generally speaking, it 
is pretty sure that this increased pressure alone, even without 



80 Clinical Pathology. 

any infection, will cause the production of fibrous overgrowth in 
the kidneys, as well as an increase in the quantity and a decrease 
in the specific gravity of the urine excreted. That the primary 
change in the kidneys is probably atrophy of secreting structure, 
while fibrous hyperplasia is a subsequent occurrence, has long 
been an accepted theory; but as I have already remarked, I do 
not think this same sequence of events has been proved to occur 
in the diseased prostate, although here also it is a plausible and 
a most convenient theory. 

Where infection exists as well, and especially where the vesical 
orifices of the ureters are more or less patent, pyelitis and surgical 
kidneys soon develope. 

Effects on the Urine. 

The residual urine almost invariably becomes alkaline, and 
is a prolific cause of cystitis. Being alkaline, phosphatic or mul- 
berry (oxalate of lime) calculi are prone to form. It has been 
estimated that nearly one-quarter of all patients with enlarged 
prostate have calculi as well. The calculus, however, being 
usually fixed rather firmly in the post-prostatic pouch, frequently 
gives no characteristic symptoms, and is difficult of detection with 
a sound. Especially is this the case where a calculus forms in 
or becomes subsequently lodged in one of the pouches already 
alluded to; or when its surface becomes covered with mucus, 
or it is surrounded by prostatic overgrowths. As already men- 
tioned, the urine may be deposited in calcareous crusts over the 
entire vesical walls. 

When chronic cystitis developes the urine presents the well- 
known characteristics of this disease. Shreds of mucus, pus, 
clots of blood, and various crystals may be found. Ammoniacal 
decomposition is frequent. The colon bacillus, imparting to the 
urine its characteristic odour, may be the infecting medium; it 
is not impossible for this germ to gain entrance to the bladder 
directly from the intestinal tract, though of course its more usual 



PLATE LVII. 




Contracted, Infected Bladder, with Thickened Walls and the Formation of 
Vesical Sacculi, from Enlargement of the Prostate Accompanied by Marked 
Cystitis. 

(From a specimen in the Mutter Museum of the College of Physicians of Philadelphia.) 



Effects on Urination. 81 

avenue of approach is through the urethra. Streptococci, staphy- 
lococci, and other micro-organisms are also found. 

The pus, the mucus, but especially the blood clots, are fre- 
quent causes of stammering in micturition; and as they are 
sucked into the eye of the catheter impart to the hand a readily 
recognized sensation. The blood may come from spontaneous 
rupture of engorged veins, or from trauma by a calculus or a 
catheter. At times the clots are found nearly filling the cavity 
of the bladder. 

When the kidneys become affected the urine becomes corre- 
spondingly altered, as seen in the early stages of interstitial neph- 
ritis from other causes. The quantity passed in twenty-four 
hours may reach ninety or a hundred ounces, or even more; 
the specific gravity will show a proportionate decrease; and 
albumen and tube casts may be detected. It should not be over- 
looked, however, that renal disease may have long antedated 
the prostatic trouble. 

Effects on Urination. 

Such widespread and serious changes throughout the urinary 
apparatus cannot fail to produce marked changes in the manner 
and the power of micturition. These will be more fully discussed 
under the heading of symptomatology, but it is well to recall 
briefly in this place the modus operandi: residual urine causes 
cystitis; cystitis causes frequent desire for urination; frequent 
urination increases the existing congestion; this in turn may 
bring on retention of urine; catheterization is resorted to, once 
or oftener; infection is very liable to occur in a bladder already 
so inflamed ; the retention and the infection of the urine produce 
circulatory disturbances in the kidney; the quantity of the urine 
is increased, and a vicious circle is established, which, unless 
the primordial cause, urinary obstruction, be removed, will 
quickly affect the patient's general health. 

The dilatation of the bladder, and consequent weakness of 

7? 



82 Clinical Pathology. 

its walls, causes two well-known symptoms — feeble power of 
expulsion, and slowness in completing the urinary act; while 
finally the inability of the vesical neck to act properly, and the 
interference with the muscles around the membranous urethra, 
cause the last portions of urine to be voided in dribbles, no power 
remaining of evacuating it in spurts. 

Effects on the Rectum. 

Enlargement of the prostate, as is well known, is very apt 
to be accompanied by haemorrhoids and prolapsus ani. These 
affections may be produced by the prostatic hypertrophy, or they 
may be due to an independent though concurrent cause. 

Venous engorgement of the prostate and the vesical neck is 
one of the main causes of sudden urinary retention, as mentioned 
above; and such venous engorgement, when prolonged or when 
recurring frequently, leads soon to a varicose condition of the 
prostatic plexus. Under these conditions incompetency of the 
valves in this plexus developes, and the blood regurgitates through 
communicating branches, and becomes dammed up in the in- 
ternal pudic and the middle and inferior haemorrhoidal veins. 
Since these all, as well as the prostatic plexus itself, empty into 
the internal iliac vein, no real relief to the venous obstruction 
ensues; but haemorrhoids develop?, and by their pain add to the 
misery of the patient. Some slight relief might occur from vas- 
cular overflow into the superior haemorrhoidal veins; but as these 
are radicles of the portal system, which has no valves, and which 
is very apt to be already congested or obstructed in persons who 
have reached the prostatic age, the superior haemorrhoidal veins 
are only too often varicose even before the middle and inferior 
become so. Phleboliths are common in the prostatic plexus. 

Not only does prostatic enlargement affect the rectum in this 
manner by producing haemorrhoids, but it may seriously obstruct 
the rectal canal when the gland is much enlarged in this direction. 
The act of defalcation is rendered difficult and painful by this 



PLATE LVII1. 




Dilatation of the Ureters and Hydronephrosis from Long-standing Prostatic 

Obstruction. 
(From a specimen in the Museum of the Pennsylvania Hospital.) 



Effects on Rectum. 83 

enlargement; obstipation is favoured, and this again reacts for 
evil by increasing the tendency to piles. 

Prolapsus is liable to follow in the wake of these other troubles, 
both from the straining in the efforts to empty the bladder, and 
from the haemorrhoidal condition of the rectum itself. 

Pelvic congestion is favoured by nearly every circumstance 
— especially by the condition of the patient's heart, kidneys, and 
liver, which have all of them, as a rule, begun to show the fibrosis 
of age; as well as by the prostatic changes produced by what- 
ever cause. 



CHAPTER V. 

CLINICAL CAUSES: RACE, AGE, OCCUPATION, 
SOCIAL HABITS, PREVIOUS DISEASES. 

Since there is very little accurately known of the causes of 
enlargement of the prostate, it is impossible to altogether avoid 
theorizing in their discussion. Not until large numbers of cases 
have been collected, in which the patient's previous history has 
been studied in considerable detail, can we hope to reach any 
definite conclusions as to the influences exerted by occupation, 
personal habits, previous diseases of the generative organs, and 
similar possible causes. 

Race. — It does not appear probable that race per se — that 
is, apart from the personal habits characteristic of any particular 
race — exerts special influence in predisposing to the disease in 
question. 

The negro race has been held to be rather less predisposed 
to this affection than is the white. Conner [52] expressed this 
opinion; Schultz I believe has made a similar statement; but the 
opinions of both surgeons appear to have been based on general 
impressions rather than on accurate records, and must hence 
be accepted somewhat guardedly. My own impression agrees 
entirely with theirs, and is based on no more substantial grounds. 
The well-known salaciousness of the negro, however, should, 
if all theories be correct, render him rather more liable to pros- 
tatic enlargement than the white man; since it is held, and 
with apparent reason, that prostatic overstrain and former in- 
flammations of the gland are among the most probable of causes 
for its overgrowth. 

In natives of India there is probably little doubt that pros- 

84 



Race and Age. 85 

tatic enlargement is abnormally frequent. Wanless [241] has 
given considerable attention to this matter, and his experience 
shows that enlargement of the prostate with complete retention 
of urine is quite common in that country. He is of the opinion 
that the chief cause lies in the excessive sexual excitement, "for 
the reason that sexual intercourse is begun earlier and continued 
later in life than ... in western coun tries.' ' Among other 
possible causes, he mentions the excessive use of curry and hot 
spices, so common to Indians. These condiments produce, 
by their habitual use, constipation and engorgement of the por- 
tal circulation; and thus a chronic congestion of the haemor- 
rhoidal vessels arises, which, as already pointed out in these 
pages, tends to impede the circulation in the varicose prostatic 
plexus. The complete urinary retention which he observed 
so often in India occurred chiefly at the time of the monsoon 
rains, when exposure and chilling were almost unavoidable; 
and in practically every case of urinary retention the cause 
was prostatic obstruction. Still another cause, and one which 
favoured the formation of phosphatic calculus, was the concen- 
tration of the urine due to prolonged work under the hot tropical 
sun; so much of the bodily fluids being thrown off by the sweat 
glands that the urine excreted was abnormally concentrated. 

In Turkey, also, prostatic troubles are comparatively fre- 
quent, chiefly due, according to Wishard [252], to the excessive 
sexual activity. In China and Japan, however, they are con- 
sidered to be extremely rare; but not probably on account alone 
of the absence of the same exciting cause. 

Age. — Age appears to exert a marked influence, although 
it is not any longer regarded as a cause sine qua non. More and 
more it is becoming recognized that it is not the prostatic enlarge- 
ment which developes first in old age, but that it is the symptoms 
of this disease which begin to manifest themselves only in the 
decline of life. Some fifty years ago or more prostatic troubles 
in men under sixty years of age were next to unknown. Sir 



86 Clinical Causes. 

Henry Thompson [224] stated that enlargement of the prostate 
never occurred under fifty-three years of age; but McGill [152] 
operated on two men, aged fifty- three and fifty-four years re- 
spectively, in whom enlargement must have existed for some 
time before the patients were seen by him. McGill [153] later 
reported another patient in whom enlargement existed at thirty- 
five years. Moullin [176] mentions the age of one of his patients 
as forty-nine years, and refers to one of Henderson's patients 
aged forty-eight years, and to other patients of forty-one and 
thirty-six years; while Dr. Mudd [179, 180] reported cases occur- 
ring in a young negro of twenty-seven, in a child of five years, 
and in an infant of thirteen months. But in spite of these unique 
examples, the fact remains that symptoms due to enlargement 
of the prostate under fifty years of age are very seldom observed. 
The researches of Thompson [224], Dittel [68], and others have 
shown that appreciable enlargement exists in about one-third 
of persons over sixty years of age, but that it produces manifest 
symptoms in only one out of every twenty. When the seven- 
tieth year has passed without enlargement of the prostate, sub- 
sequent trouble from it is very unusual. Prof. Humphrey [127] 
stated that only seventeen out of seventy-two patients between 
the ages of eighty and ninety years, and only one out of thirty 
patients over ninety years, presented symptoms of prostatic 
enlargement. 

Hunter McGuire [156] held that while enlargement of the 
prostate might exist in younger men, yet that symptoms were 
not manifested until the urinary tract, in company with the rest 
of the body, showed the results of senile changes. Such an 
explanation as this is in accord with the fact that natives of 
India and other tropical countries, as a rule, show symptoms 
of prostatic enlargement some fifteen or twenty years earlier 
than do the inhabitants of more temperate climes, their span 
of life being that much shorter than ours. 

Occupation. — It is not probable that occupation exerts very 



Social Habits. 87 

much influence over the develop ement of prostatic troubles. 
Some of the earlier writers thought that excessive horseback- 
riding caused enlargement of the prostate; and in more recent 
times bicycle-riding, especially with the seat high and the handle- 
bar low, has been held responsible for the production of this 
condition in certain patients. Probably of more real aetiological 
value in this respect than such direct causes are factors which 
exert their influence indirectly, such as a sedentary life, or other 
habits which predispose to pelvic congestion. 

Social Habits. — Under the title of "high living" may be 
grouped a certain number of influences which undoubtedly make 
the patient prone to prostatic troubles. The gouty, the rheu- 
matic, the lithaemic ; the man with hepatic and portal congestion, 
with a tendency to haemorrhoids, or to varicose veins of the legs, 
is a not unfrequent victim of enlarged prostate; and thus, as 
Wanless [241] has pointed out, in the case of the Indian noted 
above, dietetic habits or errors may become potent though in- 
direct causes of enlargement of the prostate gland. In many 
respects the causes of this malady and those predisposing to the 
formation of vesical calculus are the same, and the concurrence 
of the two affections is frequent. 

Over-indulgence in sexual intercourse has long been con- 
sidered a possible factor. From the enlarged and tender pros- 
tate of the young masturbator, to the similar organ of the old 
man who marries a young wife, — it has been common to blame 
the sexual excitement as the efficient cause; but, as remarked 
by J. William White [247] it is probably quite as logical, if not 
more so, to blame the enlarged prostate with exciting unnatural 
desires. In accord with this view is the recommendation of 
Tobin [229], who regards persistence of sexual desires in old 
men as an indication for double castration. Lydston [149] 
teaches that enlargement of the prostate is in great part due 
to its " overstrain," which he defines as hyperfunctional activity 
of the organ; this overstrain, he thinks, may have occurred in 



SS Clinical Causes. 

early or middle life (from prostatitis, urethritis, congestions from 
masturbation or ungratified sexual desires, etc.), and yet may 
not show itself until past middle life, when a general sclerotic 
tendency arises — as an old injury to the knee, for example, will 
only begin to give permanent symptoms when gout, rheumatism, 
arthritis deformans, or some similar disease makes its appear- 
ance. Harrison [116], arguing along lines somewhat opposed 
to the overstrain theory of Lydston, said: "That the withdrawal 
of a portion of that function of the prostate in which it has been 
the most actively engaged, should be followed by a continued 
activity in which growth is substituted for secretion, is not, I 
consider, pathologically illogical." But Hodgson [122], on the 
other hand, thought the enlargement might well be due to the 
necessity which the prostate was under of supplying a fluid for 
sexual intercourse after the secretion of the testicles had become 
insufficient for that purpose. 

The whole subject of the relations of the testicles to the pros- 
tate is quite obscure, and many very contradictory and appar- 
ently irreconcilable facts are at hand. The testicles undoubtedly 
furnish to the ceconomy an internal secretion, the action of which 
at the advent of puberty produces the sexual characteristics of 
the individual. If the testicles are removed before puberty, the 
boy remains of neutral sexual characteristics, and the prostate 
and seminal vesicles fail to develope. If the testicles are removed 
after puberty, the sexual characteristics which were then acquired 
do not disappear, but in some instances atrophy of the prostate 
and seminal vesicles occurs. Cryptorchism in no way prevents 
the developement of the sexual characteristics, showing that 
these depend upon the internal secretion of the testicles for their 
manifestation, and not upon the power of procreation possessed 
by the individual. From certain observations it seems probable 
that the prostate is more closely connected with the epididymis 
and the vas deferens than with the testicle, since some persons 
have been observed with two normal testicles, but with an 



Influence of Testicles. 89 

undeveloped vas deferens on one side, the corresponding half of 
the prostate being rudimentary. Likewise a unilateral develope- 
ment of the prostate has been noticed where the kidney and 
ureter on the same side were absent. Remete [198] is of the 
opinion that only normal prostates are caused to atrophy by cas- 
tration; and that the more hypertrophied a prostate is, the less 
likely is castration to produce any beneficial effect upon it. It 
is certainly true that removal of one testicle does not usually 
cause atrophy of the corresponding half of the prostate, even 
when this latter organ is normal. Moreover, Moses [172] has 
observed a case in which prostatic enlargement developed for 
the first time some years after double castration. MacEwen 
[151], similarly, advocated the theory that the testicles furnished 
an internal secretion which regulated the growth of the prostate, 
and that enlargement occurred when the testicular atrophy of 
age caused this influence to be in abeyance. Under such teach- 
ings castration as a remedial measure would be preposterous 
in the extreme. It is interesting to note the observations of 
Ciechanowski [50] in this connection. He showed that dogs are 
the only domestic animals which have an infectious urethritis. It 
is well known that of all animals dogs are most prone to enlarge- 
ment of the prostate. Moreover, in other animals castration 
invariably causes prostatic atnphy, but in dogs it often fails to 
produce any beneficial influe.ice. 

If the influential internal secretion comes from the testicles, 
it is difficult to see how ligation or excision of a part of the sper- 
matic cords or vasa deferentia could cause atrophy of the pro- 
state, unless it were by first producing a change in the testicles 
themselves; indeed, it seems not impossible that the atrophy 
is due entirely to the physiological rest which is obtained for 
the prostate through the absence of sexual desire. But, on the 
other hand, it must be remembered that castration does not 
always cause a loss of sexual desire. Mere subsidence of con- 
gestion is a much more usual result of castration than is actual 



90 Clinical Causes. 

atrophy; and the return of voluntary micturition within a few 
hours after orchidectomy only shows, in my opinion, that other 
manners of relieving the prostatic congestion would have had 
a similar effect. A further fact in favour of physiological rest 
being the cause of prostatic atrophy, however its action is obtained, 
is the observation of Hodgson [122] of a patient, aged thirty- 
five years, whose penis had been amputated some years before 
his death: in this case the autopsy showed the prostate, the 
seminal vesicles, and the testicles all much reduced in size. 

All these considerations really bring us back to the proposition 
with which we started, that excessive sexual intercourse is a fre- 
quent cause of enlargement of the prostate gland. It is not, 
however, the only cause, nor in all probability the most impor- 
tant one. This affection, as is well known, has at times afflicted 
the most moral and continent of men. 

Previous Diseases. — Probably the most prevalent of all 
causes is a preceding inflammation of some kind. The views of 
Ciechanowski [49, 50], of Greene and Brooks [102], and of Cran- 
don [54] on this subject have already been discussed, and a 
mere reference to the question is here required. Naturally the 
most frequent of these inflammations is the gonorrhoeal; and 
although many patients of over sixty years may have forgotten 
it, or may be unwilling to acknowledge it, yet a negative history 
in this respect cannot carry too much weight. Even if the in- 
flammation of the deep urethra and the prostate have not been 
of gonorrhoeal origin, the repeated attacks of congestion and the 
catarrhal exudation, from whatever cause, which frequently occur 
in this part of the human frame, are a quite sufficient cause in 
the majority of instances. 

Stricture of the urethra has been thought by some authors 
to rather militate against prostatic obstruction, from the increased 
fluid pressure which exists behind the seat of stricture tending 
to dilate the prostatic urethra. Yet a stricture of some size is 
present in many cases of enlarged prostate. I have obtained 



Previous Diseases. 91 

a history of gonorrhoeal infection or have noted the presence of 
strictures in four out of eighteen cases; and in only three of the 
remaining fourteen cases was it noted that venereal history was 
positively denied. 

Other diseases may act as predisposing causes. Among these, 
arterio-sclerosis is prominent in the nosological tables of the 
French school. Other affections, such as cardiac insufficiency, 
hepatic cirrhosis, or other diseases which cause congestion of 
the pelvic organs, should also be considered; but their action 
is very indirect, and may be a mere coincidence, not an actual 
cause. 



CHAPTER VI. 
SUBJECTIVE SYMPTOMS. 

Not every patient with enlargement of the prostate presents 
symptoms of his malady. Only about one person among every 
seven who has an enlarged prostate suffers from it; and even 
among the number who do develope symptoms there are many 
in whom these begin so insidiously that the patients will per- 
haps be unaware of any deviation from the normal until acute 
retention of urine occurs from some access of obstruction, or until 
overflow relieves the unperceived chronic retention. The affec- 
tion, on the other hand, while gradual in onset, may yet make 
its presence felt by symptoms which arrest the patient's atten- 
tion from the first. 

Some change in the urinary function is almost invariably that 
which is earliest observed, and usually consists in an increased 
frequency of micturition. This, if it occurred only during the 
day, might easily escape notice; but since it is present at night 
as well, and compels the patient to arise once or oftener from 
his sleep, is a change which is very soon observed, and for which 
an explanation is usually promptly sought. Especially with 
younger patients is this true; among the old a not unnatural 
idea exists that frequency of urination is one of the signs of age, 
and is therefore rather to be anticipated. 

Frequency of urination is due mainly to two causes: first and 
foremost, because the congestion or inflammation of the vesical 
neck and the parts around the prostate renders the bladder more 
sensitive to the presence of urine, and hence less able to support 
a large volume of fluid; and, second, because residual urine 
lessens the capacity of the bladder, which as a consequence 

92 



Frequency of Urination. 93 

reaches its usual grade of distention at shorter intervals. Be- 
sides these factors, the quality of the urine is often exceedingly 
irritating, and so its expulsion is demanded more frequently. 

Many authors have taught that the frequency of urination 
was greater at night than during the day; but, apart from the 
lack of reason for this phenomenon, I doubt its being a fact. 
Greater stress is laid upon nocturnal frequency by the patient, 
and consequently in many cases by the surgeon, merely because 
it arrests the attention sooner than increased frequency of urina- 
tion by day. A man may wash his hands eight or ten times 
during the day, and think nothing of it; but if he was to wake 
during the night with an irresistible desire to get up and wash 
his hands, he would be very sure to remember the fact in the 
morning, and to seek for an explanation. This is an extreme 
comparison, but serves to show how much more importance is 
attached by some to nocturnal frequency, than to that occurring 
during the day. These patients are not inclined to urinate 
oftener while recumbent in day-time, so the horizontal position 
cannot be given as a cause for greater frequency by night. Sleep 
may possibly be the factor of greatest importance, by lessening 
the power of inhibition over the involuntary sphincter, and by 
unconsciously increasing the resistance of the voluntary sphincter : 
thus when the patient finally wakes, his bladder is fuller, because 
a longer interval has elapsed since it was last emptied, than is 
the case during the day; and after this first sound sleep of a few 
hours, the bladder has been rendered so irritable by overdisten- 
tion that calls to urinate occur with greater frequency during 
the remainder of the night. This is given as a possible explana- 
tion by Moullin [176]; and it appears to be a fact that the first 
interval at night is the longest. Other explanations of nocturnal 
frequency have been given, such as sexual emotions during sleep ; 
but it is probable that these are as much a consequence as a 
cause. 

Of course, when cystitis developes this in itself causes the 



94 Symptoms. 

desire for urination to be more frequent; and where ulceration 
or fissure of the bladder exists, the vesical tenesmus may be con- 
stant and uncontrollable. 

The patient is likewise unable to expel the urine with his 
accustomed force. Starting the stream is difficult, much strain- 
ing being required, because there is both increased obstruction 
and decreased expulsive power. When started, the stream does 
not spurt forth in the normal parabolic curve, but tends to drop 
vertically from the meatus. A longer time than usual is required 
to pass the urine, although a smaller quantity than normal is 
passed, since the intervals are less and some residual urine 
remains. The stream is not smaller than in health, unless stric- 
ture causes it to be so. 

As the act of urination draws to a close, the urine dribbles 
involuntarily. It will thus often wet the patient's shoes; so that 
if there be much sediment present, these spots on drying will 
be incrusted with salt; from this fact alone a tentative diagnosis 
may be made. The cause of the dribbling, without the power 
being present of evacuating the last drops in spurts, probably 
lies in the impaired contractility of the bladder, which fails to 
send forward into the membranous and bulbous urethra a suffi- 
cient quantity of urine for the voluntary muscles to contract 
upon. The prostatic urethra, moreover, is unable to put itself 
into physiological continuity with the bladder, and acting as a 
more or less rigid tube, interferes with the normal flow. 

Intermittent urination has been described as present in some 
cases, but is very rare. It may be due to the ball-valve action 
of a prostatic outgrowth, which is more tightly forced against 
the vesical outlet the more forcefully the bladder contracts, and 
which permits urination only when it is floated back from the 
orifice of the urethra, during intervals of straining. If not due 
to such a cause as this, the ordinary " stammering with the 
urinary organs," as Sir James Paget [188, p. 57] termed it, affords 
a sufficient explanation. The presence of a calculus might also 
act in this way. 



Retention of Urine. 95 

Retention of urine is observed by the patient only when acute, 
or when the chronic form is accompanied by overflow. By far 
the most frequent cause of acute retention in these cases is an 
access of congestion in the vesical neck. A man who very likely 
had thought himself previously perfectly healthy will attend 
some party of pleasure, eat and perhaps drink more than he is 
in the habit of doing, be exposed to draughts, become overheated, 
or in some way commit an indiscretion ; and on his return home 
will rind himself unable to pass his urine. When relieved by 
catheterization, a similar event may not occur for months or 
years, perhaps never again. 

Overflow from retention is in some instances the symptom 
which first attracts the patient's attention. When the bladder 
has reached its limit of distensibility, as soon as any urine is 
received from the ureters, an equal amount must be discharged 
by the urethra. This involuntary leakage may be noticeable 
first only at night, when the influence of the will is withdrawn, 
or by day only during the effort of lifting some heavy object, in 
stooping to pick something from the floor, or during defalcation 
— all these acts necessitating contraction of the abdominal muscles, 
and hence diminution in bladder capacity. At later stages this 
overflow becomes a constant symptom, and unless relieved the 
patient must wear a urinal, or have his clothing constantly wet. 
The odour attendant upon this condition will frequently, in the 
poorer class of patients, at once direct attention to the true state 
of affairs. 

As previously pointed out, this symptom is much more fre- 
quent where there is no cystitis. The probable explanation 
is that no catheter has ever been passed to relieve the bladder 
of its residual urine, and to prevent its walls from losing their 
muscular tone through overdistention ; and that since no catheter 
has been passed, no cystitis has developed. 

Incontinence oj urine is extremely unusual. It has often been 
supposed to be present when the true condition was that just 



96 Symptoms. 

described — overflow from retention. Prof. Ashhurst [9] in his 
Surgery states that he "once saw a patient who, supposed to 
have paralysis of the bladder, had been taking strychnia for one 
year; the introduction of a catheter effected the evacuation of 
nearly a quart of urine, and showed the real condition to be one 
of prostatic retention with overflow." If true incontinence of 
urine does exist, it may readily be determined by catheterization, 
when the bladder will be found empty. It is probably due, when 
present, to a form of prostatic overgrowth which keeps the vesical 
orifice of the urethra constantly patent, and to inability of the 
voluntary sphincter to properly contract. In the normal condition 
as soon as urine enters the prostatic urethra, desire for micturi- 
tion is present; and where urine is constantly in this portion of 
the urethra, a constant effort of the will is required to avoid its 
passage. Hence, even if the voluntary sphincter can act normally 
during the day-time, incontinence will be present in these cases 
during sleep, except where the elastic resistance of the urethra is 
stronger than the contraction of the bladder walls. But, as a 
rule, when true incontinence occurs at all, it is present through- 
out the twenty-four hours. 

The symptoms of cystitis arising in a patient with enlarged 
prostate are the same as those in other cases of cystitis, and do 
not require extended mention in a work of this kind. Cystitis 
in these cases is practically never caused in any other way than 
by catheterization. It is theoretically possible for bacteria to 
gain entrance to the bladder in other ways, as through the kid- 
neys, directly from the rectum, and by extension along the ure- 
thra. When gonorrhoea is the cause, this last route is not un- 
frequent, but even then the gonococci are more apt to be carried 
back to the bladder by a catheter than to travel there of their 
own accord. 

Urination which was frequent before, becomes doubly so when 
cystitis developes; tenesmus is more pronounced, and the relief 
obtained by the partial evacuation is slight. A heaviness and 



Cystitis and Hematuria. 97 

burning may be felt in the perineum; suprapubic pain may be 
marked ; or the most infernal of all tortures, the burning, boring, 
uncontrollable pain in the neck of the bladder, may render the 
patient nearly insane. Pus, mucus, and blood may all be ob- 
served by the patient in his urine. 

Hematuria, though not one of the most prominent symptoms, 
is met with sufficiently often to command the surgeon's parti- 
cular attention. It may be due to the spontaneous rupture of 
varicose urethral or vesical veins, may be produced in certain 
instances by the most gentle catheterization, or may come from 
ulceration due to the prolonged cystitis or to calculus. In cases 
of marked obstruction the patient after persistent straining may 
relieve himself of only a few drops of blood. In such cases the 
blood probably comes from congested veins. If the blood is 
mixed with the urine as it flows, it probably comes from the pros- 
tate or the neck of the bladder, and may flow from an ulcer or a 
ruptured blood vessel. If it flows only at the close of urination, 
and particularly if it is clotted, it is apt to come from the post- 
prostatic pouch of the bladder. 

Symptoms of renal failure may arise at various stages of the 
disease. Nephritis may, of course, be an independent affection; 
but if not already present, is usually manifest very soon after the 
quantity of residual urine becomes great, or when infection of the 
bladder causes retrograde pyelitis. The patient may notice that 
he not only passes urine more frequently, but that the total quan- 
tity passed is greater, and that he is unaccountably thirsty. This 
increase in quantity is one of the earliest evidences of impair- 
ment of the kidneys, and should be carefully noted. If complete 
retention occurs in such cases, uraemia may rapidly supervene, 
from the inability of the kidneys in their diseased state to excrete 
under increased pressure the toxic matters whose retention in 
the blood gives rise to the well-known symptoms: confusion and 
anxiety of mind, dyspnoea, dry burning skin, feverish eye, parched 
tongue, urinous odour to the breath, hiccough and vomiting, 

8P 



98 Symptoms. 

somnolence and coma, convulsions, and death. If pyelitis be 
present from infection, irregularly recurring chills, with fever 
and sweats, may be added to the above train of symptoms. 

Closely following upon the heels of renal involvement, certain 
cardiac symptoms may appear — slight dropsy in the ankles or 
the hands, shortness of breath on exertion; palpitations; loss 
of appetite from gastric congestion; and other symptoms too 
generally recognized to need repetition here. 

Sexual power is usually lost if the prostatic disease be far 
advanced; in earlier stages intercourse may be painful, pain 
being marked especially after completion of the act. Not un- 
frequently the sexual appetite is abnormally active, and distres- 
sing priapism may occur. 

If the prostate enlarges much towards the rectum, certain 
additional symptoms may be noted by the patient. Both con- 
stipation and obstipation may arise; and the constant straining 
to urinate or defalcate may produce haemorrhoids, and even pro- 
lapsus ani, as in the case of children straining on account of 
vesical calculus. It is in this form of enlargement, too, that the 
fullness and uncomfortable feeling in the perineum, so often 
complained of, are chiefly found. 

If calculi form in the bladder, some special symptoms of this 
malady may be noted; but, as a rule, they are subordinated to 
the peculiar prostatic symptoms, since the stone is held fairly 
firmly in the post-prostatic pouch, or in one of the mucous pouches 
of the bladder. 

To attempt clinical pictures of patients suffering from en- 
largement of the prostate, by dividing the disease into certain 
stages, is a rather arduous task, since the duration of any one 
symptom or set of symptoms varies exceedingly in different in- 
dividuals. Perhaps as just an appreciation as any of this view 
of prostatic enlargement may be reached by grouping the patients 
into three classes, in the first of which, the earliest stage, may 



Stages of the Disease. 99 

be placed those patients whose chief complaint is nocturnal fre- 
quency of urination; in the second stage those patients who 
suffer occasionally from complete retention, but whose cystitis 
is insignificant, and whose general health is fairly good; and in 
the third class those wretched individuals whose retention is 
nearly absolute or quite so, who depend entirely on catheteriza- 
tion, whose kidneys are markedly diseased, and whose general 
health is on the verge of collapse. 

Some patients will remain in the first stage all their lives; 
some will within a few months pass into the second stage; and 
others will seemingly jump at once from the first to the third 
stage with scarcely an appreciable sojourn in the second. 

Some patients, on the other hand, will never be conscious of 
having passed through the first stage, but will first be impelled 
to seek medical aid for sudden retention of urine; and may then, 
if fortunate, return to the first stage and remain there all their 
lives. In many instances patients who reach the second stage 
without having been aware of the first will remain in the second 
stage throughout their lives; but in very rare instances only do 
patients pass at once from a life of seemingly perfect health to 
one of absolute and complete catheter ism. 

The surgeon should, above all things, bear in mind that a 
positive diagnosis of enlargement of the prostate can never be 
made from the symptoms alone: a physical examination is 
absolutely essential. 



t.rfC. 



CHAPTER VII. 
OBJECTIVE SYMPTOMS— PHYSICAL EXAMINATION. 

When a patient, suspected from the symptoms he describes 
to be suffering from enlargement of the prostate gland, presents 
himself to the surgeon, the first and most important physical 
sign to be looked for is the presence of a hypogastric tumor, 
with the characteristics of a distended bladder. Important as 
it is in all cases, it is above all in those patients who have been 
afflicted with chronic urinary retention and overflow that this 
precaution is indispensable. In patients such as these the hasty 
introduction of a catheter may cause immediate syncope, from 
the decrease of intra-abdominal pressure, and may lead, in a 
few days, to the patient's death from renal congestion and uraemia. 
I am well aware that Dr. Cabot's [41] recently reported experi- 
ences are at seeming variance with this time-honoured doctrine ; 
but in the cases he reported continuous bladder drainage was 
instituted in patients such as those now under discussion with 
chronic retention and overflow; and the happy results in his 
hands may have been due to the facts that the drainage was 
constant, not intermittent, and that the patients were kept under 
careful constitutional regimen. But to regardlessly plunge a 
catheter into such bladders in our office, or at a hospital dis- 
pensary, where the patients are not provided with the requisite 
facilities for proper after-treatment, will, I venture to think, 
ever remain a most dangerous and unsurgical procedure. 

Having detected such a hypogastric tumor, or having as- 
certained its absence, the patient should next be requested to 
urinate. We may then observe the facility, or the difficulty, 
with which he starts the stream; the force with which it is ex- 



Urination. 101 

pelled from the bladder ; its size, as indicative of stricture or not ; 
whether it is suddenly interrupted at any time, showing the pos- 
sible ball- valve action of a pedunculated " middle lobe," or of 
a calculus; and whether he concludes the urinary act in the 
normal manner, or if the last portions dribble out of his urethra 
without voluntary control. From a strict attention to these 
details — and no details are too insignificant in urinary affections 
— much may be learned that will prove of subsequent interest. 
The quantity of the urine just passed is then to be measured, 
and a portion of it preserved for chemical and microscopical 
examination. Its colour, odour, and the presence or absence 
of sediment, as roughly gauged by the eye, will be of immediate 
use to us in approximating the condition of the bladder and the 
kidneys. By learning the interval since the last urination, and 
knowing the quantity just passed, we may form an estimate 
of the total quantity passed in twenty-four hours; and if the 
amount of residual urine be fairly constant, this quantity serves 
as an index to the action of the kidneys. A patient who passes 
four ounces of urine, more or less, every two hours has probably 
no serious renal lesions. If he passes four ounces only every 
three or four hours, either the normal amount is not excreted 
by the kidneys, or else the quantity of residual urine is rapidly 
increasing. If, on the other hand, from a half ounce to an ounce 
is passed every ten or fifteen minutes, the patient's kidneys will 
be excreting from fifty to one hundred and fifty ounces of urine 
daily, and retention with overflow probably exists. 

If it appears that the bladder is not distended, it will then 
be proper and convenient to insert a catheter to determine the 
amount of the residual urine, and to aid in palpation of the pros- 
tate. For these manipulations the patient should be in the hori- 
zontal position. 

In many cases the surgeon will be forced to try several cath- 
eters before he will succeed in reaching the bladder. Where 
possible, for diagnostic purposes only, I prefer a metal instru- 



102 Physical Examination. 

ment, about number twenty of the French scale. I say for diag- 
nostic purposes only. For habitual use in these cases I do not 
think metallic catheters are advisable ; but for the first examina- 
tion they present many obvious advantages, such as the ease with 
which they are sterilized by being passed through the flame 
of an alcohol lamp, or by igniting alcohol which has been poured 
over them; the fact that the surgeon need touch them only at 
the extremity which does not enter the bladder; and finally, 
what is of great importance, that they serve as an exploratory 
sound both in the urethra and within the bladder. I have little 
doubt that many a soft-rubber catheter which is as pure as the 
new-fallen snow when taken into the hands, becomes oftentimes 
foully contaminated by the manipulations that are necessary 
for its insertion into and passage through the urethra. 

As this metallic catheter passes, the surgeon should note the 
presence or absence of strictures, any deviation from the normal 
line of the subpubic urethra, the height to which its vesical 
orifice is raised, and lastly the distance from the urinary meatus 
at which urine first begins to flow. 

In passing the catheter the following facts favour the diag- 
nosis of enlarged prostate: if it is found that the shaft has to 
be unduly depressed between the patient's legs before any urine 
flows, showing that the vesical orifice of the urethra is raised; 
if the urinary distance (that from the meatus to the point at which 
urine commences to flow through the catheter) is increased above 
eight inches; if the catheter deviates towards one or the other 
side as it passes through the prostatic urethra, showing an in- 
equality in size of the two lateral lobes; or, finally, if an obstruc- 
tion to the passage of the catheter is encountered at a distance 
of more than seven inches from the meatus, showing that the 
obstruction is not due to strictures, which are never present 
in the prostatic urethra. 

The surgeon should not be deceived into thinking the bladder 
has been reached when a small quantity of urine is evacuated 



Catherization. 103 

from an enlarged prostatic urethra. It will be remembered that 
this portion of the urethra may at times hold as much as an 
ounce or two of urine. 

The bladder having been reached with the catheter, the resi- 
dual urine will flow. If it flows through the catheter without 
effort on the patient's part, it indicates a fairly good vesical tone; 
but if even with the aid of his abdominal muscles the patient 
cannot expel the residual urine, and only by suprapubic pressure 
with the surgeon's hand can this be made to flow, it is evident 
that atony of the bladder is far advanced. 

The amount and the character of the residual urine will then 
be noted. From it much more accurately than from that passed 
voluntarily can the state of the bladder be inferred. Some sedi- 
ment will almost invariably be evacuated. If much is present, 
it is probable that catheterization has often been resorted to 
before, and that a more or less marked cystitis exists. Clots of 
blood are frequently found. Possibly some calcareous sediment 
will exist. The odour of the residual urine is usually ammoniacal. 
But apart from the fact of there being residual urine, its quality 
does not aid the diagnosis of enlarged prostate, merely showing 
the grade of cystitis present. 

It is next well to inject a few ounces of warm boric acid or 
saline solution, to hold the walls of the bladder away from the 
beak of the catheter. By the resistance encountered during the 
injection an idea of the condition of the bladder walls — whether 
dilated or contracted — can be obtained. 

Using the metallic catheter with all gentleness, then, as a 
sound, we can detect the approximate amount of intravesical 
enlargement of the prostate; the quality of the bladder walls, 
whether flabby and dilated, or thick, rugous, and pouched; the 
existence of calcareous crusts on the surface of the bladder, and 
of a calculus in the post-prostatic pouch, or in one of the vesical 
sacculi. 

The surgeon should next, without removing the catheter, 



io4 Physical Examination. 

introduce a finger of the left hand into the patient's rectum. In 
doing this it is usually more convenient to stand on the patient's 
left side, and to manipulate the catheter or the sound with the 
right hand. By this method of combined examination it will be 
possible in every case to detect positively any enlargement of 
the prostate. The intravesical instrument is to be regarded 
merely as a very long finger, and the amount of information that 
can be gained through it by an experienced surgeon will be a 
matter of astonishment to the tyro. 

The examining finger is not to be thrust blindly and suddenly 
into the rectum — such a procedure is both painful and danger- 
ous, since haemorrhoids with considerable proctitis may be pres- 
ent; but by a very gradual and gentle boring motion the finger 
may be insinuated so as to cause the patient very little discom- 
fort. As the finger passes the sphincter we can feel the catheter 
in the bulbous urethra, then can trace it back into the membran- 
ous urethra, but in case the prostate is enlarged it will be im- 
possible to trace it further. The finger next encounters the pros- 
tate in the anterior rectal wall, and, passing to either side, to- 
wards the ischial tuberosities, the outline of the enlarged lateral 
lobes can be detected. In most cases it will require a long finger 
to reach well beyond the enlarged prostate, and to feel the tip 
of the catheter in the retro-prostatic pouch; but this should 
always be attempted, as we thus obtain a very much more ac- 
curate idea of the size and shape of the prostate; and where the 
beak of the catheter is not long enough to reach the floor of the 
pouch, it may be possible to elevate this by the finger in the 
rectum, and thus to detect a calculus which might otherwise 
have escaped notice. By directing the patient to close his mouth 
and "bear down," the prostate may be forced into reach of the 
finger even when very much enlarged. 

Before withdrawing the finger the state of the seminal vesicles 
should be examined if they are within reach. The existence of 
high internal hemorrhoids can also be determined. 



PLATE LIX, 




Combined Method. 105 

If it has been impossible to satisfactorily examine the rectal 
relations of the prostate on account of its size or its high posi- 
tion in the pelvis, an assistant may be able, by well regulated 
but firm suprapubic pressure, to bring it within reach of the pal- 
pating finger; or it may be gently drawn down by the aid of the 
catheter within the bladder. 

Such an examination as this will enable us to say positively 
in every case whether there is or is not an enlarged prostate. 
The surgeon should remember, however, that many symptoms 
of enlargement of the prostate may exist without there being any 
enlargement present; and that enlargement of the prostate may 
exist and yet give rise to no symptoms; and, furthermore, that 
even where characteristic symptoms and prostatic enlargement 
are both found, one is not necessarily caused by the other. Hence 
no surgeon should undertake any plan of treatment hastily, or 
without due consideration in cases of this kind. Indeed, it is 
often best to temporize for awhile, until by making repeated and 
careful examinations all possible sources of error have been 
eliminated, and the condition of the parts involved has become 
familiar to the surgeon. 

In the local examination such as has been described, it has 
been assumed that the urethra was freely open to instrumentation ; 
but in very many patients this is not the case: strictures, false 
passages, and obstruction by the prostate itself may any or all 
of them render such an examination impossible; and hence 
oftentimes the best that can be done is to improve the condition 
of the urethra, and so persist until a satisfactory examination 
finally becomes possible. Enlargement of the prostate is not a 
disease in which haste is advisable. 

Besides the condition of the urinary tract, the surgeon should 
always make a thorough general physical examination. The 
signs of age, whether premature or not, should be sought for: 
the condition of the arteries, the arcus senilis, the cardiac action, 
and the general circulation all require attention. The general 



106 Physical Examination. 

health should be determined — the appetite, the habits as to 
smoking and drinking, the digestion, the amount of sleep usually 
obtained, and the ability to pursue the usual occupation — none 
of these should be neglected. The state of the heart and kidneys 
is of the utmost importance: increased renal pressure and the 
consequent toxaemia so soon make their presence known by 
cardiac hypertrophy, with increase in size of the left ventricle, 
evidenced by displacement of the apex-beat downwards and to 
the left, and by the stronger and longer first cardiac sound in 
the same situation, with the well-known accentuated second 
aortic sound; that any surgeon who pretends to accuracy in 
diagnosis would be guilty of great oversight if he neglected a 
careful examination of the heart. Of even greater importance 
than the detection of cardiac hypertrophy, is it to discover the 
early signs of dilatation of the heart. It is probable that the 
accentuation of the second aortic sound above referred to is not 
an early sign of hypertrophy, so that where it has existed for 
some time, the evidences of dilatation may be shortly expected; 
here the weakening of the first apical sound, with the production 
of a mitral systolic murmur, and increase of cardiac area to the 
right of the sternum, with perhaps occasional murmurs of incom- 
petency over the aortic valves, I regard as the most valuable 
local signs. But as further evidences of cardiac dilatation I 
would call special attention to the various results of venous con- 
gestion, such as dyspnoea, oedema of the extremities, varicose 
veins, haemorrhoids, hepatic and gastric congestion, loss of ap- 
petite, and flatulency with indigestion. 

The chief means we have for determining the condition of the 
kidneys is, of course, by means of urinalysis. Without pretend- 
ing to deny the value of microscopical examination of the urine, 
I am free to confess that I place much more reliance on the total 
quantity excreted in twenty-four hours, on the specific gravity, 
and on the percentage of uraea present, than I do on the presence 
of tube casts or albumen. These latter, unless in excessive 



Urine. 107 

amount, I have come to regard as nearly normal in persons past 
middle life; but where the excretion of solids, as shown by the 
uraea content, is diminished, and where the total amount of urine 
excreted is constantly much above the normal, I am far more 
chary of undertaking serious operative measures than in the 
former case. 

The normal amount of urine excreted in twenty-four hours is 
from forty to fifty ounces (1200 to 1500 cc); the normal amount 
of uraea in the same period is five hundred grains or over (35 
grammes); and the normal specific gravity is 1017. Naturally, 
where the total quantity of urine is increased, unless an increase 
in the amount of uraea excreted occurs, the specific gravity will 
be decreased; hence it is not sufficient to calculate the amount 
of the uraea present from a single specimen of urine: the whole 
quantity passed in twenty-four hours must be considered. The 
normal percentage (2.8 per cent.) of uraea may be much de- 
creased, with the increased quantity of urine excreted, yet the 
kidneys cannot be seriously impaired if the total amount of uraea 
eliminated remains nearly normal. 

An examination of the blood will be of interest; though it 
cannot be expected to aid in the diagnosis. The percentage 
of haemoglobin is the most important point to be determined, 
since by it we gain a fairly accurate index of the patient's ability 
to withstand operative treatment. 



CHAPTER VIII. 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS ; 
PROGNOSIS. 

The diagnosis of prostatic enlargement is not usually difficult. 
In the first place, the clinical history, or the sequence of symp- 
toms, is almost invariably characteristic. The increased fre- 
quency of urination, in a patient past the prime of life, will at 
once direct our attention to the prostate. Retention may have 
necessitated the passage of a catheter once or oftener. If the 
retention has been due to strictures, the patient will usually be 
quite well aware of the fact, and will be more inclined to confess 
their presence than perhaps a younger man who may have the 
memory of their onset and early stages more vividly in his mind, 
and may regard them as more of a reproach. 

Many of these patients will have been under treatment by 
another practitioner, and will know their own malady well, so 
that frequently the surgeon has only to confirm a diagnosis already 
made. But it is well not to forget that the previous physician, 
no matter how high his reputation, may have erred in his diag- 
nosis, and that therefore in enlarged prostate as in other affec- 
tions it is safe not to take a ready-made diagnosis. 

As a rule, the age of the patient and his nocturnal frequency 
of urination are sufficient to arouse our suspicions. As has been 
already mentioned, the general aspect of the patient, together 
with a urinous odour, due to overflow from retention permitting 
his clothing to be more or less constantly wet, will in some in- 
stances enable the acute observer to anticipate the diagnosis 
even before the patient states his troubles. Even in cases seem- 
ingly obscure at first, a detailed history of the case and a com- 

108 



Diagnosis. 109 

plete and strictly systematic physical examination will invariably 
enable a correct diagnosis to be made. It is only where small 
or impassable strictures prevent instrumental examination of the 
vesical surface of the prostate that a diagnosis becomes at times 
impossible, unless sufficient enlargement can be felt by the rec- 
tum to render an intravesical examination superfluous. 

The stage of the disease is usually more easily determined 
from the symptoms than from the physical examination. The 
most important change in the life-history of these patients is 
that produced by cystitis, which unfortunately is nearly 
certain to make its appearance sooner or later. Naturally, 
the earlier the stage at which prostatics are first seen, the greater 
is the hope of cure. When the urine is constantly of a specific 
gravity below 1010, the action of the kidneys is manifestly im- 
paired, and the disease may be considered quite far advanced. 
The longer infection is absent, the longer is the disease apt to 
endure in a quiescent state, the patient being troubled mainly 
with frequency of urination until the accumulation of residual 
urine produces overflow. 

The cardinal principle by which we determine the size of any 
body is by learning the distance between its surfaces, or its diam- 
eter ; to accomplish this in the case of an organ situated as is the 
prostate, it is absolutely essential to gain entrance to the bladder 
superiorly and to the rectum below. It is not sufficient merely 
to insert a finger into the rectum and to palpate the prostate 
thence; nor is it enough to learn by catheterization that the 
urinary distance is increased, that the subpubic urethra deviates 
from the normal curve, and that there is residual urine. By the 
rectal touch frequently no enlargement can be detected while 
decided urinary obstruction exists from overgrowth into the blad- 
der or urethra; and the information gained from the passage 
of a catheter alone is manifestly incomplete. Hence before mak- 
ing a positive diagnosis the surgeon should resort to the com- 
bined examination with a sound or catheter within the bladder, 
and a finger in the rectum, as already so often insisted upon. 



no Diagnosis. 

But merely to ascertain that the bulk of the prostate gland is 
increased is not to make sure the diagnosis of " enlargement of 
the prostate." Enlargement may exist from various morbid 
processes, such as chronic prostatitis, prostatic abscess, calculus, 
or tumors of the prostate; and it is chiefly by attention to the 
clinical history of the case that a distinction between these dif- 
ferent forms of enlargement is reached, although, as will be 
mentioned under the head of differential diagnosis, the sense 
of touch will aid us here as well. 

I have not heretofore mentioned the cystoscope as an aid 
to diagnosis, and this omission has been intentional, since I con- 
sider this instrument of very little use in the average case, and 
feel that in some patients its injudicious employment may be 
productive of harm. Where a satisfactory diagnosis cannot be 
made without the employment of the cystoscope, the surgeon 
need not hope to make one by its aid; and under such circum- 
stances it is, in my opinion, quite as well for the experienced sur- 
geon to do either a suprapubic cystotomy or a perineal urethro- 
tomy, and thus to explore the bladder and prostate with the eye 
which nature has placed at the end of his index ringer. In these 
cases drainage is the all-important indication, and while evil 
results from over-instrumentation may be few and far between, 
and while the cystoscope is only slightly more dangerous than an 
ordinary catheter, yet since so little of value can be gained by 
its use, it is best to avoid it as a rule. Surgeons there maybe, 
and probably are, who are more expert with complicated machin- 
ery than with their hands, and who will always prefer the use 
of a machine to work performed by their ringers; such operators 
employ an elabourately complicated needle-holder, a dental en- 
gine, a Bottini incisor, or a cystoscope, largely because of their 
admiration of the mechanical perfections of the instrument in 
question; and what excuse there is for the habitual use of the 
cystoscope in the diagnosis of prostatic hypertrophy, is when it is 
in the hands of those surgeons who employ it daily for other 



Cystoscopy. in 

purposes. To advise the general practitioner, who may have 
need of a cystoscope only once in five years, to insert it into 
the distorted, inflamed, and susceptible urethra of prostatics, 
is to be guilty of great indiscretion, to say the least. It is quite 
unfortunate enough that an instrument of some kind must be 
passed to enable us to complete our examination; and it is to 
avoid repeated instrumentation that I have recommended a 
metal catheter in the first instance ; but we should shun the error 
of making the remedy worse than the disease. 

In my own experience I have rarely learned more from a 
cystoscopic examination, in any patient, than I knew already, or 
could accurately infer. The form and shape of the intravesical 
growth I have been invariably more able to determine from pal- 
pation by the aid of a sound or catheter than through the medium 
of vision by a cystoscope. The employment of the cystoscope, 
indeed, is only too often like that of the skiagraph at the present 
day — much abused, and of value chiefly as confirming diagnoses 
already made. 

It is an important thing to be able to distinguish between the 
two main classes of prostatic overgrowth — the glandular and the 
fibrous — since the same operation, if one is indicated, is not 
usually advisable for both varieties. 

The prostate which has undergone a change which is chiefly 
adenomatous in character is larger and less dense than the nor- 
mal organ, and is usually not firmly fixed, unless its great size 
make it so; the rectal mucous membrane glides easily over its 
surface; the general outline of the two lobes and the intervening 
commissure can often be distinguished; and well-defiend adeno- 
matous masses (prostatic tumors) of greater than the normal 
density may at times be palpable in the substance of the gland; 
while the surface may present similar protuberances, sessile or 
pedunculated. 

The bladder in such cases is more apt to be dilated than con- 
tracted; cystitis is either slight or absent; and the patient may 



ii2 Differential Diagnosis. 

reach the stage of retention with overflow before he has observed 
any marked deviation from his usual health. The duration of 
the malady and of the frequent urination will usually have been 
several years at the least. 

Where the fibrous prostate has developed, the organ will be 
but slightly enlarged, or may in rare instances even become smaller 
than the normal. Its density is increased; periprostatitis as a 
rule has occurred, causing the formation of fibrous tissue about 
the prostate, so that it is less movable than normal; the rectal 
mucous membrane will be less able to glide over the surface of 
the altered gland; and the outlines of the prostate will be more 
difficult to determine. No protuberances are, as a rule, to be 
felt on its surface, and so dense is its whole substance that em- 
bedded tumors, if any be present, cannot be detected. 

The bladder, in the case of the fibrous prostate, has probably 
early been exposed to infection: it is found contracted, its walls 
thickened, and its surface perhaps pouched. As a consequence 
of this, distressing symptoms have made themselves prominent 
early in the case; and the patient may give a history of only a 
few months' or a year's duration; while he next to never reaches 
the stage of overflow, as the constantly recurring desire for urina- 
tion has impelled him to keep his bladder nearly empty, by 
catheterization or otherwise. 

It is the contemplation of these two clinical pictures — the 
one a dilated and passive bladder, the other a contracted, infected, 
irritable bladder — that makes it seem improbable that the two 
forms of prostatic disease are due to the same causes: inflam- 
matory action seems so pronounced in the latter class, and so 
latent in the former. 

Differential Diagnosis. 

Very many of the symptoms and of the physical signs, as well, 
presented by prostatics, are known to occur in other affections. 
Hence it frequently becomes necessary for the surgeon to con- 



Atony of the Bladder. 113 

sider the differential diagnosis of these cases, and at times to form 
his ideas by the method of exclusion. 

Atony of the bladder, being itself often caused by prostatic 
obstruction, may first claim our attention. The symptoms of this 
malady, even when produced by another cause, may very closely 
simulate those attendant upon enlargement of the prostate: thus 
the patient will find himself required to strain immoderately to 
start the flow of urine, will be long in emptying his bladder, and 
may be aware that some portion of his urine constantly remains 
unevacuated. As a consequence of these changes the frequency 
of urination may be increased, and it may become impossible to 
differentiate the two affections from a recital of the symptoms 
alone. But the surgeon will very easily distinguish mere vesical 
atony from the train of symptoms and their complications due 
to prostatic enlargement as soon as he seeks a cause for the 
symptoms. The history of the patients may be the same, but 
by simply passing a catheter, and palpating the prostate at the 
same time from the rectum, enlargement of this organ can be 
readily excluded. Of course, if the vesical atony be due to stric- 
ture, it will not always be possible to make this combined exami- 
nation, and therefore in those cases we cannot be absolutely sure 
that prostatic enlargement does not coexist. 

Hence where strictures of the urethra are present, the ex- 
clusion of prostatic hypertrophy is more difficult. Although the 
age of the patient may render the presence of the latter affection 
extremely improbable, yet many of the symptoms are the same 
— slow, difficult urination, with atony of the bladder, as well as, 
possibly, haemorrhoids and prolapsus ani. But the passage of 
an instrument of full size into the urethra will show obstruction 
more or less complete to exist within seven inches of the meatus ; 
and if entrance to the bladder can be gained, the absence of 
enlargement of the prostate is readily determined by the com- 
bined rectal and vesical examination already described. In case, 
however, of an impermeable stricture with chronic retention, it 
9P 



ii4 Differential Diagnosis. 

will not be possible to satisfactorily examine the prostate until 
these conditions are relieved. 

Cystitis, when unaccompanied by stricture or prostatic en- 
largement, is unattended by residual urine, and although the 
crebruria may simulate that of overflow from retention, this 
affection is readily proved not to exist by the passage of a 
catheter; while combined intravesical and rectal examination 
will reveal a prostate of normal size. 

The same remarks apply to the very rare condition, paral- 
ysis of the bladder. A more common mistake is to suppose 
that patients suffering from retention with overflow have paral- 
ysis of the bladder; it being a sad fact that too many physicians 
are in the habit of diagnosing the rarest complaint possible, and 
of overlooking very common causes for the malady of the 
patient, no matter what it is. 

Where a vesical calculus exists, it is not liable to be mis- 
taken for an enlarged prostate unless it is both firmly fixed in 
the neighbourhood of this organ and so thickly coated with 
mucus that no grating sensation is imparted to the sound. But 
even under such circumstances there may be no residual urine, 
which is, as already insisted upon, a nearly invariable accom- 
paniment of every enlarged prostate producing symptoms; and 
there will probably not be the characteristic change in curve 
of the subpubic urethra. If the calculus is prostatic, or even 
if it merely coexists with an enlarged prostate, a positive diag- 
nosis is more difficult. In about one out of four patients, it is 
to be remembered, a calculus complicates the enlarged prostate. 
Bleeding is more common in cases of calculus than in those of 
enlarged prostate alone, and the pain is less constant, and more 
confined to times when the bladder contracts upon the concre- 
tion, or when the patient is actively moving about. The pain 
frequently radiates to the end of the penis. In uncomplicated 
prostatic enlargement pain is usually an insignificant symptom. 
In calculus, moreover, the greatest frequency of micturition is 



Prostatitis. 115 

during the day, and the patients are not apt to be disturbed 
much at night. A skiagraphic examination will at times detect 
the presence of a calculus when other means have failed. 

Probably the most difficult diagnosis of all is that from poly- 
poid growths in the bladder, which when springing from the 
region of the prostate may very closely simulate a pedunculated 
" middle lobe" of this organ. But in nearly all forms of vesical 
tumor other than prostatic, spontaneous haemorrhage is an early 
and conspicuous symptom, and is usually not attended by much 
pain. In most cases, moreover, fragments of the tumor are 
passed in the urine, so that a microscopical examination may 
render the true condition of affairs manifest. 

Tubercle of the bladder may occasionally simulate enlarge- 
ment of the prostate by the symptoms it produces. But it prob- 
ably always coexists with similar disease elsewhere in the body, 
most often in the epididymis. Hence in doubtful cases this should 
be recollected, and the spermatic cords and seminal vesicles 
examined as well. The cystoscope here may be of considerable 
aid, enabling the surgeon to localize a tuberculous ulcer in the 
bladder, and thus render it accessible for topical treatment. 
But it is in precisely such cases as these, where there is haemor- 
rhage from the ulcer sufficient to cloud the medium, that the 
cystoscope is most disappointing. If the tuberculous disease 
affects the prostate, there can usually be detected areas of soften- 
ing, in the irregularly enlarged organ; and although it might 
at times seem difficult to distinguish between areas of softening 
in a prostate somewhat denser than normal (tuberculous disease), 
and areas of hardening in a rather less dense organ (adenomatous 
enlargement with prostatic "tumors"), yet other features in the 
case will usually enable the diagnosis to be made. 

Chronic prostatitis usually succeeds upon the acute form 
of the disease, which is sufficiently manifested by its abrupt onset, 
positive inflammatory character, excessive tenderness on rectal 
exploration, and by its occurrence, generally as a sequel to gonor- 



n6 Differential Diagnosis. 

rhoea, in a younger patient. The chronic inflammation is chiefly 
characterized by prostatorrhcea, which is very unusual in simple 
enlargement. 

Abscess of the prostate likewise usually follows acute in- 
flammation, but may be traumatic in origin. Besides the history 
of the case, the course of this affection is so acute compared to 
that of enlargement of the prostate, that confusion is not likely 
to arise. Moreover, the abscess may point in the urethra, the 
rectum, or the perineum; and palpation may enable a diag- 
nosis to be made before rupture renders it certain. 

There is another affection of the region of the prostate, de- 
scribed as sclerosis of the neck of the bladder, and which has 
been especially studied by Chetwood [44]. Its symptomatology 
and morbid anatomy do not appear to differ materially from 
those accompanying post-inflammatory atrophy of the prostate 
as described by French writers. The symptoms of this affection 
and of those of senile enlargement of the prostate are almost 
precisely alike; but by means of the combined examination the 
absence of any enlargement of the prostate is readily determined. 

Malignant disease of the prostate is chiefly of the adeno- 
carcinomatous character. Sarcoma is very rare. Carcinoma of 
the prostate is distinguished by the great local and referred pain, 
which latter shoots down the inner sides of the thighs, and may 
simulate that due to stone in the bladder by being felt at the end 
of the penis. The prostate is found to be densely hard, enlarged, 
and firmly fixed ; the rectal mucous membrane becomes adherent, 
and infiltration of the surrounding tissues finally becomes mani- 
fest. Haemorrhage into the bladder or urethra may occur spon- 
taneously. This is rarely the case in benign enlargement. In 
this connection it should not be forgotten that malignant changes 
in formerly benign overgrowths are not at all unheard of, and if 
we may believe the researches of Albarran and Halle [3], may 
even be expected in more than one-tenth of all patients. 

Sarcoma, when found in the prostate, may be distinguished 



Prognosis. 117 

by the tendency which it possesses in common with other malig- 
nant tumors towards production of cachexia; this cachexia is 
developed more rapidly than is the case with carcinoma, and 
the rate of growth of sarcomata is, as a rule, more rapid. 

Prognosis. 

A question of considerable importance and much interest 
in connection with enlargement of the prostate is that of prog- 
nosis. In few other diseases is it so necessary for the surgeon to 
know what may be accomplished by the various methods of treat- 
ment possible, and in probably no other class of cases is he more 
severely blamed for errors in judgement. It is not sufficient, 
indeed it is neither ethical nor humane, to hope that the patient 
will die of some intercurrent affection before any necessity arises 
for instituting active treatment on behalf of his enlarged pros- 
tate; and hence every physician or surgeon who has such cases 
under his charge must give careful thought and attention to each 
individual patient, and must know whether the expectation of 
life will be lengthened or decreased by the treatment he pro- 
poses undertaking, or whether the certainty of a life of consider- 
able discomfort for a rather prolonged period is not less to the 
patient's ultimate advantage than the immediate risk to life 
incurred by a somewhat severe and shocking operation, which, 
if successful, will enable the patient to live out his natural term 
of life in ease and comfort. 

There are, then, two main questions to be solved in this con- 
nection: first, whether the patient's life can be saved, prolonged, 
or at least not sacrificed by the treatment to be pursued — that 
is to say, the question of mortality; and, second, whether the 
patient's sufferings will be relieved wholly or in part, or whether 
no change at all can be obtained — that is, the question of final 
functional results. 

Under medical treatment and catheterism there is practically 
no possibility of directly terminating the patient's life; with 



n8 Prognosis. 

the understanding that every antiseptic precaution be taken in 
catheterization, his life may even be prolonged, and in certain 
cases made very comfortable. Many a patient who has to pass 
a catheter only once or twice in the twenty-four hours will live 
a life of perfect ease, and will round out his days without inter- 
ruption. But where the catheter has to be passed frequently 
— that is to say, as often as four to six times in the twenty-four 
hours — or where its passage at even longer intervals is attended 
with pain or difficulty, catheterism must be considered at the 
present day an insufficient remedy, except in those who are 
already on the threshold of the grave. The expectation of life, 
moreover, in patients treated by catheterization, has been shown 
by Harrison [114] and by Lydston [148] to be, in the average, no 
more than four or five years; so that it is clear that the life of 
the average patient is shortened by such treatment. 

The next mildest form of treatment is drainage of the bladder. 
By this means may be obtained relief of the cystitis, and conse- 
quently of the tenesmus, pain, and general unrest, in a certain 
number of cases. In my opinion, it is applicable chiefly to those 
in a very debilitated condition, or to the very old. Drainage 
by a permanent catheter introduced through the urethra can 
seldom long be endured, and is usually only to be employed 
in preparing the bladder for a radical operation. The successes 
of Thompson [225], McGuire [155], and others in treating these 
patients many years ago by means of suprapubic permanent 
drainage, and of Harrison [in] by means of a perineal tube, 
should not be forgotten at the present day; and while we recog- 
nize the inadequacy of such methods to restore the patient to his 
normal condition, yet in a limited number of cases they are still 
useful. Especially is this so in patients with very bad cystitis, 
and where some immediate relief is imperative. In such cases 
so radical an operation as prostatectomy will almost surely kill, 
unless time can be obtained to relieve the cystitis, to get the 
kidneys into fair condition, and to improve the general health of 



Mortality. 119 

the patient. In patients such as these, the formation of a per- 
manent suprapubic fistula by McGuire's method, or, if the pro- 
state be not too large, simple perineal prostatotomy with the 
introduction of a tube, will afford almost certain relief to the 
urgent symptoms, and in many instances will enable the con- 
stitution to withstand prostatectomy at a later date. Neither 
castration, vasectomy, nor ligation of the internal iliacs will act 
sufficiently quickly in such cases; indeed, in my opinion, these 
operations are no longer to be considered desirable under any 
circumstances. 

The mortality attendant upon the various operative pro- 
cedures will be discussed in greater detail in a future chapter; 
it is sufficient here to consider their relative danger. 

In the first place, it is quite evident that of those deaths, and 
they are few in number, that do follow the institution of drain- 
age by suprapubic cystotomy or perineal prostatotomy, only a 
very small proportion, if, indeed, any at all, can be blamed upon 
the operation itself. Practically every patient who submits to 
such an operation is already in an extremely critical condition, 
and without such intervention would die at least as soon as, prob- 
ably sooner than, if he had not been operated upon. 

The Bottini operation stands midway between the palliative 
and the radical methods of treatment; and while its mortality 
is slightly less than that of prostatectomy by either the supra- 
pubic or the perineal route, yet its results are so extremely un- 
certain, both as to immediate relief of symptoms and as to per- 
manency, that it is not, in my opinion, an operation to be advised 
except in a very limited group of cases. 

The radical operations have a distinct mortality per se y even 
when all mitigating circumstances have been considered, and 
all doubtful cases have been excluded. A few patients die from 
the operation itself, and we cannot escape the conviction that in 
such cases they would not have died at that time if no operation 
had been performed. Hence the conscientious surgeon will make 



120 Prognosis. 

it a matter of the utmost importance to so select his cases that 
he will not be forced to say to himself, "Had my treatment been 
different, my patient would have recovered, or at any rate he 
would not have died as a result of my treatment." 

The proper treatment, therefore, of prostatics — a convenient 
term adapted by Belfield [18] from the German Prostatiker and 
the French prostatique — resolves itself into a choice of remedies, 
not into any hard and fast rules which may not be transgressed. 
It has been well said that he is either a fool, or at best a surgeon 
of very limited experience, who knows of only one method of 
treatment for a certain class of cases; and while I myself may 
maintain that a certain treatment is the best, I do so with the 
distinct reservation that it is not immediately applicable to every 
case. 



CHAPTER IX. 

TREATMENT: CONSTITUTIONAL; CATHETERISM ; PREVEN- 
TION OF COMPLICATIONS ; AND TREATMENT 
OF COMPLICATIONS. 

Patients afflicted with enlargement of the prostate should 
to preserve their health make everything in their life subservient 
to regularity and temperance. By regularity I mean the avoid- 
ance of everything which is not habitual; there should be no 
exceptions to the amount of sleep, to the hours of meals, to the 
daily constitutional walk, to the hour of retirement, to the dis- 
tance travelled, to the quantity of food and drink, to the amount 
of intellectual labour, or to anything which arises in a man's life. 
And temperance is epexegetical of regularity: not only should 
everything conjoin to allow the patient to pursue the even tenor 
of his way, but there should be moderation in all things; his 
habits should embrace the happy medium in which alone the 
path of safety lies. 

Such habits as these are possible only for the man who is in 
easy circumstances. The day-labourer, the overworked artisan, 
who knows not in the evening whence will come the money to 
buy the morrow's bread, cannot, if he would, lead a life of such 
orderly quiet as is enjoined on his more fortunate neighbour. 
And it is only where this life can be led that the purely palliative 
treatment can be expected to render the patient comfortable. 
Where it cannot be pursued, radical treatment is urgently de- 
manded to restore the individual to his. former condition of in- 
dependence. 

i. Constitutional Treatment. 

(a) Hygienic Treatment. — Regularity and temperance being 
our watchwords, they are to be applied to every aspect of the 



122 Constitutional Treatment. 

individual's life. If possible, suitable climatic conditions should 
be obtained, the cold winters of the north being avoided by so- 
journs in lower latitudes. The patient's clothing should be 
warm enough to avoid chilling at all seasons of the year. Flannel 
in cold weather, and silk in hot weather, should be worn next 
the skin. Especially important is the avoidance of wet feet. 
Waterproof shoes should be worn, or sandals of rubber should 
be constantly carried in the overcoat pocket, ready for use in 
any emergency. Of more value even than these precautions, 
oftentimes, is the invariable rule to change the shoes and stock- 
ings immediately upon the return from being caught in any 
dampness, no matter how trivial it may appear. Even if the 
feet do not feel wet, it is a safe precaution to change the shoes 
and stockings as a matter of habit. A very slight ischsemia of 
the cutaneous circulation may bring on alarming prostatic, vesical, 
and renal congestion, with retention of urine and even uraemic 
symptoms in a very short space of time; and of no conditions 
than these is it more true that an ounce of prevention is worth 
pounds of cure. It is less dangerous to become overheated than 
to be chilled, provided chilling is not the consequence of becom- 
ing overheated. To perspire freely is good for these patients; 
and for the purpose of aiding the excretory action of the skin 
regular bathing should be enjoined, provided it can be done in 
a well heated and ventilated bath-room. It will be found safer 
with patients of advanced age to depend on moderate sweating, 
followed by a carefully administered sponge bath, or even on 
merely rubbing the skin dry, where an attendant cannot be pro- 
vided for bathing, than to risk exposure in a poorly appointed 
bath-room. The water should be warm; if kidney disease is 
present hot baths are a valuable adjuvant in securing proper 
excretion of the waste products. Cold baths are to be condemned. 

Hot sitz baths immediately before retiring are very grateful 
in some cases. 

The bowels should be regularly opened at least once each day; 



Hygiene. 123 

and even if they act normally, the use of a brisk saline cathartic 
is to be enjoined at least once a month. Straining in defalcation 
causes general pelvic congestion, and this reacts unfavourably on 
the prostate. 

The urine is never to be retained beyond the accustomed 
period of three or four hours during the day. Holding it longer 
will be very apt to render the patient unable to evacuate it when 
he finally makes the attempt. The bladder is to be scrupulously 
evacuated as the last thing just before getting into bed. If the 
patient is forced to urinate during the night, it is better for him 
to use a urinal without leaving his bed, and thus avoid exposure 
and unnecessary exertion. Of course, where the patient is unable 
to make his water in the supine position, he will usually have 
to leave his bed entirely for this purpose. Socin and Burck- 
hardt [212] condemn the practice of urinating in the supine 
position, stating that the extra straining thus necessitated pre- 
disposes to atony of the bladder. The patient may try, at all 
times of the day, urinating in the knee-chest position, so as, if 
possible, to overcome the retroprostatic pouch by the aid of 
gravity. 

The patient should, on the other hand, be discouraged from 
passing his urine unnecessarily often. With a bladder not 
markedly diseased it should seldom be imperative to evacuate 
less than six or eight ounces of urine at a time. 

Six to eight hours is enough for a patient to spend in bed at 
night. If more sleep is required, a nap may be taken in the day- 
time. He should not sleep long in the same position, changing 
after an hour or so from the back to one side, and again to the 
other, so as to avoid congestion of the vesical neck and prostate. 
Where exercise cannot be taken, massage is an invaluable sub- 
stitute. 

His daily occupation should be such as does not require exer- 
tion either constantly in mild degree or occasionally to excess. 
It should not interfere with his meal hours, nor by causing mental 



124 Constitutional Treatment. 

worry or fatigue interfere with his repose at night. He should 
"go softly all his days." 

(b) Dietetic Treatment. — Certain articles of diet are notori- 
ously unwholesome even for the healthy man, but in addition to 
eschewing these, the prostatic should likewise avoid certain edibles 
usually regarded as harmless. Vegetables of all kinds are per- 
missible, and meats in moderation. The frequent association 
of kidney disease makes poultry a more suitable animal food 
than butcher's meat. Of this latter food, especially to be avoided 
are pork, ham, sausage, veal, and to a less degree beef. Stewed 
sweetbreads, boiled fish, stewed or raw oysters, are wholesome 
articles, and may largely replace meat. Clams and crabs are very 
unsuitable. Eggs and cheese are to be partaken of with caution. 

Potatoes should be taken sparingly; green vegetables, pro- 
vided they do not upset the stomach, are to be allowed liberally, 
as they tend to keep the bowels soluble. Spinach, cauliflower, 
asparagus, stewed celery, squash (marrow vegetable), and similar 
vegetables are the best. Tomatoes, peas, and beans are to be 
allowed only occasionally, and in great moderation. Corn is not 
to be taken at all. For solid eating none is so suitable as well- 
boiled rice. Cereals of all kinds may be given, especially barley ; 
also wheaten and rye bread, but never hot, nor in any amount 
when fresh. 

Salads and highly seasoned gravies and sauces are to be 
avoided, although lettuce or even fresh celery, with French 
dressing, may be occasionally indulged in. 

Of fruits, the most suitable are prunes, especially when stewed 
without much sugar; stewed rhubarb is another suitable dish; 
grapes, particularly those of California; oranges, lemons, pears, 
and apples, in moderate quantities may serve occasionally to 
vary the monotony. Figs, bananas, peaches, blackberries, straw- 
berries and raspberries are harmful in the order named. 

Almost any kind of milk dessert is permissible, including 
tapioca, sago, rice and bread puddings, as well as ice-cream. 



Diet. 125 

Great abundance of fluid should be taken, except, of course, 
where, from renal complications, polyuria is the most distressing 
symptom. Water is, of course, the most valuable beverage, and 
the most constantly palatable; and is probably of quite as much 
value uncarbonated and in its natural state. But the various 
alkaline waters may do good where the urine is acid and the 
diathesis gouty. The drinking of milk is to be especially en- 
couraged. Alcoholic beverages are best avoided altogether; but 
here, as elsewhere, I think that long-continued habits should 
not be rudely disturbed, and prefer to allow my elderly patients 
to continue in the very moderate use of whiskey with their meals, 
as in such quantities, and for such patients, it acts as an un- 
deniable aid to digestion. .Whiskey is probably, when good, the 
least harmful form in which these patients can take alcohol; 
the light Rhine wines also, Hock, Moselle, and others, may be 
taken, but Port and Madeira are to be studiously avoided. Claret 
may be allowed in moderation. An excess of sugar throws hard 
work on the kidneys and bladder, and predisposes to urinary 
fermentation. Tea is better than coffee, and coffee than choco- 
late; but none of these beverages should be taken more than 
once a day, and then in the morning, and with a liberal dilution 
of milk or cream. 

Food should not be partaken of late at night; if possible, 
dinner should be the midday meal. No fluid should be taken 
during the evening nor on retiring for the night. Patients often 
find themselves able to sleep the night through without urinating 
if this rule is observed. Yet in some gouty patients where the 
urine is much concentrated, a glass of water drunk just at bed- 
time will, as remarked by Moullin [176], by diluting the urine 
and rendering it less irritating, have the same effect. 

(c) Drugs. — Very few drugs are of any permanent service 
in enlargement of the prostate. Tonics are usually indicated 
for the general health; and of these I would recommend the 
time-honoured combination of the tincture of nux vomica, with 



126 Constitutional Treatment. 

dilute hydrochloric acid and some simple bitter, such as the 
compound infusion of gentian, as being as suitable as any other 
prescription. Strychnine itself does not seem always to have 
the same happy effect on the stomach that the tincture of nux 
has, and unless the heart demands training I usually prefer the 
tincture. 

As already mentioned, an occasional cathartic is useful in 
every case; but many patients are habitually constipated, and 
must, even in addition to a diet carefully selected for this purpose, 
take a laxative almost constantly. For this purpose I am in the 
habit of employing either pills of aloin, belladonna and strych- 
nine, or, which is preferable if the patient will take it, the fluid 
extract of cascara sagrada (Rhamnus Purshiana, U. S. P.). These 
remedies should be commenced in active doses, and the amount 
taken reduced, as soon as may be, to the least possible required 
to produce the desired effect. Some patients will keep their 
bowels happily regulated by chewing senna leaves or rhubarb 
root, of which they become almost fond in time. Compound 
licorice powder is another favourite remedy with some. Enemata 
of cold water may be useful in stimulating the lower bowel, and 
in decreasing the pelvic congestion. Iodoform or glycerine sup- 
positories may be employed in preference to injections; or 
ichthyol, locally, or by mouth ten drops in a capsule three times 
daily. The patient will usually learn what form of medication 
suits him best, and will after experiencing a few times the dis- 
comforts of constipation and haemorrhoids, be very eager to avoid 
their recurrence, by properly regulating his diet and medicines. 

The tone of the bladder is best maintained by preventing 
overdistention. Atropine should never be given long at a time; 
hence the preference expressed above for cascara sagrada over 
the use of A. B. & S. pills. Strychnine in one form or another 
is about the only drug which seems to have any influence on the 
contractility of the bladder; and as in the form of the tincture 
of nux vomica it acts favourably on the stomach, the intestines, 



Drugs. 127 

the bladder, and also the heart, is probably the most useful 
single drug we have. Its prolonged use, however, is injurious, 
patients becoming nervous and fidgety when it is persisted in. 
The dose should not, as a tonic, exceed one-fortieth of a grain 
three times a day; usually one-sixtieth is sufficient, except, of 
course, where stimulation is required. 

For the heart, besides strychnine, as recommended above, 
an occasional course of digitalis will be found beneficial. This 
drug also increases the amount of urine excreted by increasing 
the forward pressure in the kidneys, and to flush these organs 
out it is at times an invaluable remedy. It should never be 
continued long, both on account of its cumulative action and the 
danger which always exists of exciting an intractable gastritis. 
The kidneys are best controlled by diet, no drug being of any 
lasting benefit. 

For the prostate itself there is no specific. I am, however, 
a firm believer in the occasional value of ergot. During an 
accession of prostatic and vesical congestion, often accompanied 
by a fit of the piles, and with retention of urine, there are few 
prescriptions which afford the patient such comfort after the 
urine has been evacuated by catheter, as the following: 

I^. Ext. Rhamni Purshian. Fl f *ss 

Ext. Ergotse Fl f § j 

Ext. Hamamelis Fl f §iss. 

M. S. — Teaspoonful three or four times daily, in water. 

For the urine there are many drugs. It is readily diluted 
by increasing the amount of fluid, especially water and milk, 
ingested; and may be concentrated by withholding fluid and 
promoting perspiration. Boric or benzoic acid will be found 
useful for alkaline urines, and may be given separately or com- 
bined, about five grains of benzoic acid being prescribed with 
double the quantity of sodium borate, to ensure solution. Salol 
is an excellent urinary antiseptic, and with boric acid, may be 
employed for considerable periods — several weeks at a time — 



128 Catheterism. 

without producing injurious effects. Sodium benzoate is another 
good drug; urotropin, however, I prefer. With piperazine I 
have little experience, and seldom employ it or the more irritat- 
ing drugs, such as uva ursi, cubebs, buchu, and copaiba. For 
excessively acid urine the best remedies are a change in diet, 
especially a reduction in the amount of sugar, and dilution by 
an increase in the ingested fluid. The neutral or alkaline salts 
of potassium and sodium will usually be found to aid the change 
in reaction. The officinal solution of potassium citrate may be 
freely taken; and the alkaline mineral waters and purges may 
be advised. 

2. Catheterism. 

It is my opinion that every patient should have a trial of 
catheter life, or catheterism, as it is called. I am well aware 
that many patients commence to fail as soon as this course of 
treatment is entered upon, and such should certainly be cared 
for by other means; but it is usually impossible to say who 
will and who will not be benefitted by regular catheterization, 
and the only sure way to determine this question is to try and 
see. 

Catheterism will cure no patients. Some individuals may 
have their symptoms relieved, and be able to dispense with the 
catheter in the course of a few weeks; but such cases are prob- 
ably those where the onset of the symptoms was due largely, if 
not entirely, to congestion of the prostate and its surrounding 
structures, and not to permanent obstruction from enlargement. 

But before entering upon the subject of catheterism in detail 
it will be convenient to discuss first the different varieties of 
catheters to be employed, and then their sterilization and pre- 
servation. 

(a) Catheters. — Catheters are divided by systematic writers 
into the flexible, the semi-flexible, and the inflexible, of which 
three types, the Nelaton or soft-rubber catheter, the English 



PLATE LX. 




Catheters. 129 

or webbed catheter, and the metallic catheter, are good represen- 
tatives. 

The soft-rubber catheter, known by Nekton's name, should 
for the purposes of prostatic surgery be fourteen or sixteen inches 
long at the least. Its tip should be solid beyond the eye, and 
the eye should be moulded in the manufacture of the instrument, 
and not cut afterwards. By having the tip solid there is no 
space for the collection of filth, to act as a ready culture-medium 
for germs, and by having the eye moulded, not cut, there is the 
assurance that its edges will be smooth and well turned, so that 
by no possibility can the urethra be damaged. The catheter 
employed should be new ; and as soon as one commences to grow 
old it should be discarded. There is great danger of old rubber 
breaking and of leaving a portion of the catheter in the urethra 
or bladder, if it becomes brittle; and when it has become flimsy 
and collapsed it is exceedingly difficult to introduce. 

The English catheter is made of webbing, covered with shel- 
lac, which renders its surface smooth, and gives a certain degree 
of rigidity to the instrument. These catheters are provided with 
stylets. Cheap English catheters are not worth buying: they 
are thin walled, break easily, or at least become creased, even 
when in the urethra, and are sometimes perforated by the stylet 
when in use. The tip of an English catheter is hollow like the 
rest of the shaft, and contains the end of the stylet. If the tip 
were solid, there would be constant danger of the stylet protrud- 
ing at the eye, and thus lacerating the urethra. These catheters 
are of such consistency that when placed in hot or even moderately 
warm water they become limp, and can be readily moulded to 
any desired curve; and by the action of cold water they again 
become quite rigid, and will retain their form long enough for 
use. When not in use, they are kept on the stylet, which should 
be of the curve desired. As a rule, they are used without the 
stylet, but this may be allowed to remain in place if more firm- 
ness be required. When the curve requires to be altered during 



130 Catheterism. 

use, this is readily accomplished by partially withdrawing the 
stylet, as will be more fully described on a subsequent page. 

The elbowed (coude) catheter of Mercier is a very valuable 
instrument made of much the same material as the English cath- 
eter. Unlike the English catheter, however, the instrument of 
Mercier should have its tip solid ; the beak is about three-quarters 
of an inch in length, and is set at an angle of no degrees with 
the shaft, which is straight, the eye being in the flexure between 
the two; or there may be one eye on each side of the beak. It 
is important to purchase only catheters of this variety where 
the angle is produced in the process of weaving, and to avoid 
those catheters, of which there are many in the shops, which have 
been woven straight, and which have had the end subsequently 
turned up. This latter variety is cheaper, but the elbow seldom 
is sufficiently pronounced when new, and very soon disappears 
altogether by the catheter resuming its original linear form. The 
catheter employed by Leroy d'Etiolles had a longer elbow, which 
was set at an angle of 130 degrees with the shaft. 

The double-elbowed (bi-coude) catheter is, as its name implies, 
one where the terminal portion has a second angle about one 
inch and a half back of the first. It is made of the same material 
as that with the single elbow, but the second angle is not so abrupt 
as the first. Where the tip of the single-elbowed catheter is 
hollow it may be passed with a stylet of similar form, when by 
partially withdrawing the stylet a second elbow will be produced 
at any desired situation (Guyon). There is little risk of the 
stylet protruding at the eye in its passage, as will be seen by 
practising these manoeuvres before introducing the catheter. 

All catheters made of webbing should have the eye woven in 
the making ; to have it cut subsequently leaves a sharp and often- 
times ragged or ravelling edge. 

It is convenient in these, as well as in curved metallic ure- 
thral instruments, to have some indicator on the handle to show 
which way the beak is pointing. So far as I know, there is at 



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Catheters. 131 

present no better way provided of determining this point in the 
case of the Mercier catheter than by recollecting the relation to 
the beak borne by the printing on the shaft. With the English 
catheter a similar precaution may be employed, except when it 
is used with the stylet, when the ring-like extremity of this guide 
will indicate the direction of the curve. 

Metallic catheters have usually a curved beak. The original 
Mercier catheter was silver, but, as already mentioned, it is 
usually now made of webbing. The normal curve of the subpubic 
urethra is that of the circumference of a circle whose diameter 
is three and one half inches; and the length of curve is the arc 
subtended by a chord of two and three-fourths inches; but the 
curve of the catheter is usually subtended by a chord of only 
two and five-sixteenths inches. (Van Buren and Keyes.) 

In the urethra altered by prostatic enlargement, however, the 
curve is considerably increased, having both a greater diameter 
and a greater length of arc; so that various metallic catheters 
with " prostatic curves" are found on the market. Probably the 
largest required curve is one which is one-third of a circle whose 
diameter is five and a half inches. It is important not only 
to have the curve thus larger, but for the curve to be greater at 
the tip than elsewhere, thus approaching the instrument of Mer- 
cier in type. At the very least, the curve should be continued 
to the very end of the catheter. 

The tip of metallic catheters should be solid, to allow no 
nidus of infection to exist, and it is even more indispensable 
here than in the case of the webbed catheters for the eye to be 
made in the mould, and not to be subsequently cut out by a 
punch. The shaft should be at least nine inches in length beyond 
the beginning of the curved beak, since with an instrument of 
customary length the bladder might not be reached. 

Metallic catheters should be plated with nickel, silver, or 
some other non-corrodible metal; and should be provided with 
two eyelets at the handle, to serve as indicators of the direction 



iS 2 Catheterism. 

in which the beak is pointing. Or the catheter may be S-shaped, 
the opposite direction of the two curves effectually indicating the 
position of the beak. 

In all these catheters for use in prostatics the eye should be 
amply large, and should be placed in the concavity of the curve ; 
or one eye may be placed on each side, at different levels, but 
between a half an inch and an inch from the end. It is also 
best to use an instrument of as large a calibre as the urethra 
will conveniently take, since there is thus less danger of entering 
or of producing false passages, and a better chance exists of 
evacuating pus or blood clots from the bladder. 

(b) Sterilization of Catheters.— Soft-rubber catheters may 
be boiled. If they are stewed, the elasticity and tone is lost very 
soon; but if the water is brought to the boiling-point before the 
catheter is placed in it, the rubber will stand repeated boilings 
of from three to five minutes without showing material degenera- 
tion. Where boiling cannot be employed, as is the case under 
some circumstances with rubber catheters, and with all catheters 
made of webbing and coated with shellac, chemical disinfection 
must be used * Carbolic acid, in the strength of one part to 
twenty of water, has been much relied upon, the catheters soaking 
in such a solution for twenty or thirty minutes. This substance 
has the disadvantage, however, of rendering the catheters so 
flimsy, even when the solution is cold, as to make them very 
difficult to use; so that latterly I prefer a ten per cent, solution 
of formalin, which is itself a forty per cent, solution of formalde- 
hyde gas in water. The well-known hardening effect of formalin 
preserves the desired form of these catheters admirably. Some 
surgeons have found the use of formalin so irritating to the mucous 
membrane of the urethra as to cause great pain to the patient, 



* Mr. Moullin [176], however, states that Messrs. Maw, Son and Thompson make 
for him aseptic catheters, semi-flexible, which "will stand boiling for five minutes every- 
day for months together (provided they are kept straight while in the boiling water and 
are drained well afterwards)." 






PLATE LXIII. 





Sterilization of Catheters. 133 

as well as at times to produce a rather severe urethritis. I have 
not myself, however, seen any such effects. Wolff [256] advises 
the use of a one per cent, solution of corrosive sublimate in equal 
parts of glycerine and water, the catheters being germ-free at 
the end of six hours. This solution is claimed to possess the 
threefold merit of sterilizing the catheters, preserving their elas- 
ticity, and rendering them ready for instant use without the inter- 
vention of any other lubricant. 

Metallic catheters are readily sterilized by boiling. The prac- 
tice of merely igniting alcohol which adheres to their surface 
is by no means sure as a disinfectant, unless the catheter is 
already of more than ordinary cleanliness. Where catheters are 
religiously cleaned and boiled after each time they are used, this 
method will serve very well as a rapid and efficient manner of 
sterilization; but if the catheter has been put away with septic 
blood clots or inspissated pus in its interior, it is idle to expect 
the momentary application of a flame to its surface to render 
infection impossible. 

All catheters should be subjected to the ordinary rules of sur- 
gical cleanliness immediately after being used. After being 
washed clean in soap and hot water, and their cavities thoroughly 
syringed out, and emptied if need be of clots, etc., by means of 
absorbent cotton mounted on a stylet, they should be returned to 
the antiseptic solution ; or if there will be no need for their use 
soon again, they may be wrapped in a sterile towel, after being 
shaken dry in the air. 

Rubber preserves its elasticity better when kept wet, and it 
should never be laid away in a dry warm place. 

A powder known as trioxy methylene, which slowly gives off 
gaseous formol, has been much used abroad for the purposes of 
sterilizing webbed and rubber catheters. It is placed in the hol- 
low of a specially constructed stopper, and its vapour passes 
through perforations in the lower surface of this stopper into 
the interior of the glass case in which the catheters are contained. 



134 Catheterism. 

Where this powder cannot be obtained, a piece of absorbent 
cotton moistened with formalin may be placed in the catheter 
case. 

Where the patient has to catheterize himself, and must care 
for his catheters in person, it is expedient to render his necessary 
manipulations as simple as possible. Moullin [176] recommends 
that he keep in his wardrobe, or wherever else may be most con- 
venient, two glass cases, long enough to contain the catheters 
without bending them; one case should hold a small piece of 
absorbent cotton moistened with formalin, and the other should be 
filled with boric acid solution, which should be changed every 
day. A douche bag filled with a strong solution of green soap 
should also be provided. The catheters, which should at least 
equal in number the number of times during twenty-four hours 
that the patient must catheterize himself, and which are of course 
flexible or semiflexible, should be rinsed through thoroughly with 
the soap solution and hot water immediately after use, and then 
be placed in the boric acid solution. Once each day, or oftener, 
all the catheters should be boiled, and then stored in the for- 
malin case until ready for use. It appears to me that this is 
rather a complicated process of sterilization for the average pro- 
static ; and I would at any rate suggest that after use and cleans- 
ing with the soap and water, the catheter should be placed in 
the formalin jar, and remain there for six hours at the least. It 
may then be transferred to the boric acid solution for some time 
before use, and thus will have been sterilized by the formalin, 
and will have had the irritating qualities of this antiseptic re- 
moved, before being brought into contact with the urethra. By 
this plan also the necessity of boiling is avoided, and however 
useful this may be for metallic and india-rubber instruments, I 
cannot but think it destructive to those constructed of webbing 
and covered with shellac. 

English catheters should be kept mounted on a stylet of 
proper curve, and be immersed in the antiseptic solution (for- 



Plate lxiv. 




miifli mmitmiuwwm 



Aseptic Pocket-case 



for Catheter. Natural Size. 



Care of Catheters. 135 

malin or carbolic acid) for a half -hour before they are used; 
they should then be thoroughly cleansed and dried. Freyer 
[89] is quite content if he can accustom his patients to the con- 
scientious use of soap and hot water. The hands, foreskin, glans 
penis, and the urethra of the patient should be suitably prepared 
for catheterization as directed at page 136. 

When the patient travels, he must be able to carry his catheter 
with him in an aseptic and yet not too bulky a form. For this 
purpose various pocket cases are found in the shops, of which 
the best are made of metal, so that some formalinized cotton can 
be kept in them along with the catheter, which is coiled up so 
as to occupy less space. An ordinary metallic soap-box may 
be used. 

(c) Lubricant. — For many years olive or castor oil has been 
employed as a lubricant for catheters. These substances may be 
sterilized by boiling, but unfortunately they do not remain sterile 
very long; and the addition of strong antiseptics is very apt to 
roughen the surface of webbed instruments in time, or else is 
ineffectual in sterilizing the oil. Yet I am myself quite satisfied 
to use carbolized olive oil of the strength of one to twenty. Senn 
[210] recommends " sterilized vaseline, with the addition of 2 \ 
per cent, carbolic acid or 1 per cent, of formic aldehyd.'' Burck- 
hardt [212] prefers a one per cent, solution of salicylic acid in 
sterilized olive oil; while, as already mentioned, Wolff [256] lubri- 
cates and at the same time sterilizes his catheters in a one per 
cent, sublimated solution of glycerine and water. An aqueous 
solution of boroglycerine is another useful lubricant. 

When the patient catheterizes himself, it is far safer as well 
as more convenient for him to be provided with numerous flasks 
each containing ten cubic centimetres of the lubricant, which he 
then squeezes directly into the urethra, thus minimizing the risk 
of infection. 

(d) Method of Passing Catheter. — The choice of catheters 
should always be for the soft-rubber first, then for the Mercier, 



136 Catheterism. 

then the English, and finally, in rare instances, the metallic instru- 
ment. There is probably no department of surgery in which 
practice, habit, natural aptitude, a light hand, good temper, and 
patience, are of such paramount importance as in catheterization. 
It will seem to the patient as if one surgeon rushed at him from 
the other end of the room with a crowbar in his hand, prepared 
to plunge it into the unfortunate man's urethra, while another 
surgeon will gain entrance to the bladder before the patient has 
really become aware of his manoeuvres. And it is next to im- 
possible to inculcate by precept the many tricks which may be 
required to insinuate a rebellious catheter into an obstructed 
urethra: only by example and long-continued practice may the 
uninitiated learn these matters. 

It is always good to have clean hands, and should be a char- 
acteristic of the surgeon ; but where a flexible catheter is to be 
passed ordinary cleanliness will not suffice. As it is necessary 
always to hold such an instrument close to its point of entrance 
into the urethra, and as therefore it must be fingered throughout 
its whole length during its introduction, the surgeon's hands 
should be sterilized as for a serious operation before he presumes 
to touch the sterile catheter. 

The glans penis and the foreskin of the patient should be 
washed with soap and water, the fatty subtances then removed 
with seventy per cent, alcohol, and finally the glans should be rinsed 
with corrosive sublimate solution (1 to 1000) ; the anterior urethra 
should next be flushed out, first, if possible, by directing the patient 
to pass what urine he is able, and then by an injection of boric acid 
solution (two per cent.). The catheter then being taken in 
hand, should be thoroughly lubricated by being dipped in a suffi- 
cient quantity of the lubricant, which is then allowed to run up 
its whole length; or an injection of the lubricating fluid may 
be made directly into the urethra. The end of the catheter is 
then to be carefully inserted into the meatus. I may say here 
that where there is a prospect of oft-repeated and long-continued 



PLATE LXV. 





Aseptic Cases for Catheters. 
The U-shaped tube has a special flask for the lubricating fluid. 



Catheterization. 137 

use of the catheter, I think it wisest to do a meatotomy at once, 
when the meatus is not amply large. 

The Nekton catheter is so flexible that it must, as already 
mentioned, be held close to the penis, and urged forward an inch 
or less at a time. In fact, the urethra should seem rather to 
swallow the catheter than that the latter was being forced in. 
It is well to know just how long the catheter is, so that the amount 
already introduced may be readily gauged from the portion 
which still remains within the hands. If when the tip of the 
catheter has reached the prostatic urethra it will not readily pass 
onwards, the finger should trace its course through the perineum 
and from within the anus, and an attempt should be made to 
direct it on into the bladder. If the catheter feels firmly im- 
bedded, it should be partly withdrawn, and then again passed 
forwards with a quicker and somewhat rotatory motion, as its 
tip may have been engaged in a false passage or entangled in a 
fold of mucous membrane. At the same time, with the finger in 
the rectum the catheter's point should be kept against the upper 
wall of the urethra, out of the usual neighbourhood of false pas- 
sages and obstructions. If, finally, no reasonable endeavours 
will succeed in introducing the soft-rubber catheter into the blad- 
der, this instrument should be withdrawn, and a Mercier elbowed 
catheter passed. The manner in which this catheter is to be 
handled does not differ materially from that just described; but 
it should be the surgeon's care that the elbowed beak follows the 
roof of the urethra, as it will thus be more likely to glide over 
the raised internal orifice of this canal. 

The Mercier catheter failing as well, the surgeon should next 
attempt the English catheter, moulding it to a proper curve 
before introducing it into the urethra. If it will not pass with- 
out the stylet, it should be withdrawn, and then re-introduced 
with the stylet in its interior. When the obstruction previously 
encountered is again met, if slight persistence in pressing the 
handle well down between the patient's thighs will not cause 



138 Catheterism. 

the beak of the catheter to surmount the obstruction, the surgeon 
may by withdrawing the stylet about a half an inch raise the 
beak a sufficient distance to enable it to ride over the prominence 
of the prostate. It is very rarely ever necessary to employ silver 
catheters in recent cases — that is to say, in cases where the ure- 
thra has not been much tampered with by other instruments. 
Occasionally, however, where there has been long-standing in- 
flammation of the parts about the prostate and the vesical neck, 
the tissues are so hard and resistant that although no real mechan- 
ical obstruction may exist to the passage of a catheter, yet the 
flexible and semiflexible instruments are not strong enough to 
press apart the sclerosed structures. In cases such as this, the 
use of a metallic catheter may be indispensable; but in employ- 
ing one it should be constantly borne in mind that even the very 
minute amount of force that is justifiable here will do an incal- 
culable amount of damage unless the channel of the urethra is 
strictly adhered to. Hence the surgeon should make it a golden 
rule to cling close to the roof of the urethra, and to never for an 
instant use any degree of force, however small, out of the median 
line. He will be far more apt to succeed in the object he has 
in view if he keeps cool and avoids metal instruments. 

If the first examination of the patient have been conducted 
in the manner advised in Chapter VII, much valuable informa- 
tion will have been acquired as to the character of the urethra 
and its obstructions, so that at a later date catheters can be passed 
with a fair amount of intelligence and certainty. 

The patient should use himself the catheter which is most 
easily passed ; but he should never be allowed a metallic instru- 
ment. The soft-rubber catheter is the most harmless, but so 
great seems to me the danger of infection from the necessity of 
handling it so extensively during its introduction — an objection 
which applies also, though in less degree, to the Mercier catheter 
— that I have a strong preference for the English catheter for the 
patient's use. These catheters are so firm as to be readily intro- 



Frequency of Catheterization. 139 

duced by holding their outer end only, as with the metallic 
catheter, and are at the same time sufficiently flexible to render 
them safe in not very skillful hands. Under these circumstances 
they should, of course, be passed without the stylet. 

The frequency with which a prostatic should be catheterized 
depends entirely upon the distress occasioned by the residual 
urine, provided always that the latter is not increasing in quantity. 
As a rule, however, it will be found that when a patient has as 
much as four ounces of residual urine he will be so regularly 
disturbed at night as to require the complete evacuation of his 
bladder by catheterization once in the twenty-four hours. The 
most suitable time for this evacuation is just before retiring for 
the night. It is the least inconvenient time possible for the 
careful attention to personal and instrumental preparation, and 
is also a time when the emptying of the bladder will be apt to 
give the longest relief for the ensuing night. 

Many a patient, nevertheless, who has this amount or even 
more of residual urine will not be sufficiently inconvenienced by 
it to necessitate regular catheterization at all. The surgeon should 
not, on the other hand, dismiss such a patient from his care, but 
should attentively watch him, and by passing a catheter every 
three or four months ascertain whether the residual urine is in- 
creasing. It is in just such quiescent cases as these that the re- 
sidual urine accumulates, increment by increment, until atony of 
the bladder is well advanced, and overflow from retention occurs ; 
or absolute retention with its complete dependence on the catheter 
makes the remaining days of the patient one long drama of 
misery. 

If the residual urine, therefore, is found in the course of 
weeks or months to be steadily increasing in quantity, the sur- 
geon should not hesitate, even though no compelling symptoms 
exist, to resort at once to habitual catheterization, as the only 
preventative of vesical atony. 

Under either of these circumstances, then — the presence of 



140 Prevention of Complications. 

symptoms, or the steady increase in residual urine without symp- 
toms — the catheter should be used once in the twenty-four hours 
for four ounces or less of residual urine. If six ounces are pres- 
ent, use it twice, night and morning ; and add one more catheteri- 
zation for each additional two ounces of urine up to six times 
daily. When the required number of catheterizations exceeds 
this limit, some other form of treatment is urgently demanded, 
even though catheterism appears to maintain the patient's normal 
health. 

3. Prevention of Complications. 

The most serious complications which it is our duty to en- 
deavour to prevent are cystitis, retention of urine in all its varie- 
ties, calculus, Bright's disease, and uraemia. 

Cystitis. — The causes of cystitis in cases of enlargement of 
the prostate being almost exclusively infection from without 
through instrumentation, the paramount importance of aseptic 
habits in this particular is readily recognized. All that was said 
as to the means of sterilizing urethral instruments, the manner of 
introducing them, and the state of the surgeon's hands and of the 
patient's urethra, glans penis, and foreskin, should be borne in 
mind; as far as possible all instrumentation should be avoided; 
and, moreover, the diet and drugs habitually advised should be 
such as to prevent vesical congestion or irritability. The state 
of the urine should be closely watched, and over- acidity or al- 
kalinity strenuously combated. If strictures exist, the preven- 
tion of cystitis is even more important, as the bladder will have 
been in a state of less resistance for some time. Hence the stric- 
tures should be systematically dilated, the benefits derived from 
this treatment when carefully conducted far outweighing the 
dangers of infection. The passage of large-sized steel sounds 
through the prostatic urethra also will tend to prevent progres- 
sive obstruction from the diseased organ, in accordance with 
the teachings of Mr. Reginald Harrison [no]; and by thus 



Cystitis. 141 

maintaining an open channel for the urine, may postpone if not 
entirely prevent the developement of cystitis. 

Although the prevention of cystitis is so important a part 
of treatment, it is a sad fact that the treatment of fully developed 
cystitis constitutes the greatest part of the surgeon's labour in 
these cases; and this is perhaps so because an uninflamed blad- 
der rarely gives rise to feelings of discomfort on the patient's 
part or of anxiety on the part of his attendant. But some pa- 
tients are so subject to urinary fever, that although they may 
recover from an attack, yet, this complication being ever present 
in the minds of both surgeon and patient, extraordinary methods 
are necessary to avoid its recurrence. In these patients more 
than any others should instrumentation be as limited as possible, 
and when necessary the most " pedantic precautions" (Senn, 
[210] ) against infection should be observed. Quinine or opium, 
or both, should be administered some hours before the catheter 
is used, and should be repeated at intervals of three or four hours 
afterwards until all danger of chills and other infective manifesta- 
tions has passed. As it is probable that both urethral and urin- 
ary fevers are occasionally due to the septic condition of the 
urine itself, and not to any new infection carried in by the in- 
strument, it is well also to give these patients a course of urinary 
antiseptics, such as salol, urotropin, sodium benzoate, etc. Since, 
moreover, these manifestations of infection are predisposed to 
by interstitial nephritis, every effort should be made from the 
beginning of treatment to get the kidneys into good working 
order and to keep them so. 

Retention of Urine. — There are several varieties of reten- 
tion of urine, which it will be convenient to define at the outset, 
that we may know the conditions indicated by each term. First 
there is (1) Acute Complete Retention: here the patient, who 
was before able to evacuate his urine wholly or in part, becomes 
unable to do so — all the urine is retained, and the condition is 
acute. Second there is (2) Chronic Complete Retention, where 



142 Prevention of Complications. 

the patient depends absolutely upon the catheter as a means of 
emptying his bladder, being unable, quite as much as in the 
first variety of retention, to expel a single drop of his own ac- 
cord — all his urine is retained, but the condition is chronic. 
Third there is (3) Chronic Incomplete Rentention without Dis- 
tention of the Bladder, where a certain portion of urine is con- 
stantly retained, but where the major portion is evacuated volun- 
tarily — a chronic condition, where, without the bladder being 
overfilled, residual urine exists. Finally there is (4) Chronic 
Incomplete Retention with Distention of the Bladder, where so 
much of the urine is retained that the bladder has reached the 
limit of its capacity, and overflow from retention results. 

Guy on [108] mentions still another variety of retention, which 
he terms acute incomplete retention, and says it is very rare. I 
have not observed such a condition myself, and as M. Guyon 
leaves its symptoms somewhat to the imagination, I am unable 
to describe it more fully than by giving its title. 

Acute Retention. — 

1. Acute Complete Retention. 

Chronic Retention. — 

2. Chronic Complete Retention. 

3. Chronic Incomplete Retention without Distention. (Residual 

Urine.) 

4. Chronic Incomplete Retention with Distention. (Retention 

with Overflow.) 
The first variety may attack either a patient with no residual 
urine, or one in whom the urine has been partly retained for 
some time. In either case it is almost invariably due to a sud- 
den increase of congestion in the prostatic urethra and the vesi- 
cal neck. Hence for its prevention all those things should be 
avoided which have already (page 122) been mentioned as favour- 
ing this state of affairs. Exposure, chilling of the skin, wet 
feet; retaining the urine an undue time; eating or drinking 
too freely; lying too long abed — all these things should be studi- 
ously avoided. 



Retention of Urine. 143 

The second variety, chronic complete retention, is almost 
invariably the result of absolute atony of the bladder. It arises 
probably most frequently as a consequence of the third variety, 
where the residual urine slowly accumulating ultimately over- 
comes entirely the power of the bladder to contract and expel 
any portion of its contents. In some instances it is due to me- 
chanical obstruction from the growing prostate, which prevents, 
even if the tone of the bladder is preserved, any urine from 
being expelled. In exceptional cases retention of this kind suc- 
ceeds immediately upon acute retention, the bladder being then 
so very much distended that it never regains its contractility. 
This complication is hence to be prevented by regularly evacuat- 
ing the residual urine by catheterization, and at times by mould- 
ing the prostate as it grows, so as to keep an open water-way 
from the bladder; also by preventing acute retention. 

The third variety, that where a varying amount of residual 
urine is present, is the nearly universal state of prostatics, and 
is practically unpreventable. In the early stages of enlarge- 
ment, if no residual urine exists, absence of symptoms is usual, 
and instrumentation in an attempt to hinder the growth of the 
prostate by pressure will be more likely to cause cystitis or pro- 
statitis than to prevent the developement of a post-prostatic 
pouch. 

The fourth variety, retention with overflow, succeeds upon the 
third when a very small amount of contractile force is still pre- 
served in the bladder, and when the urethra is not absolutely 
obstructed by the prostatic growth. It rarely occurs where cysti- 
tis is present ; and is best prevented by regular aseptic catheteri- 
zation during the earlier stages of the disease. 

Atony of the Bladder.— Atony of the bladder, it is thus 
seen, is an even more dreaded attendant upon prostatic obstruc- 
tion than retention of urine, of whatever variety; for where 
atony is extreme, it cannot be remedied even by restoration of 
the urethra and vesical neck to their normal condition. Even 



144 Prevention of Complications. 

though the whole obstructing prostate be removed successfully, 
and an easy entrance to the bladder be gained by catheters, yet 
the power of contractility lost from prolonged overdistention will 
in some cases never be regained. Fortunately, however, we no 
longer give so gloomy a prognosis as it was customary to do 
only a few years ago : we have learned through the brilliant suc- 
cesses of Mr. Freyer and other surgeons that in some instances 
where for fifteen or twenty years the patients had depended ab- 
solutely on the catheter for the evacuation of every drop of their 
urine — that in some cases such as these the complete removal 
of the enlarged prostate has within a few months or even weeks 
brought back contractility and good expulsive power to bladders 
that were thought before operation to be hopelessly diseased. 
And although, as I say, we can no longer regard atony which 
is apparently complete as entirely irremediable, we should never- 
theless spare no pains to prevent its developement. To this end 
the bladder should never be allowed to become distended. Where 
the catheter is employed habitually, great pains should be taken 
to ensure its entrance into the bladder with the evacuation of 
all the residual urine, not merely drawing off the ounce or so 
that may exist in the dilated prostatic urethra, and leaving the 
true residual urine to accumulate until either complete chronic 
retention or retention with overflow has developed. And where 
the catheter is not habitually employed, nothing should prevent 
regular periodical examinations to determine the question whether 
the residual urine is increasing or not. 

Calculus. — The prevention of the formation of calculi in the 
bladder extends not alone to those means usually employed in 
patients where no prostatic enlargement exists; for in prostatics 
we have constantly present a stagnant pool of urine in the blad- 
der, ready at any moment of neglect to crystallize around a 
blood clot or a plug of mucus or pus. The customary dietetic 
treatment must be employed; the urine should be carefully 
watched, and maintained in a dilute and unirritating condition; 
and the residual urine should be systematically evacuated. In 



Vesical Haemorrhage. 145 

patients with a family history of calculus, or with a lithaemic 
tendency, the rule of non-interference with quiescent bladders 
where the amount of residual urine is not increasing, must be 
abandoned ; and on any occurrence of bladder irritability a stone 
should be carefully searched for. 

Haemorrhage into the Bladder. — This is a complication of 
extreme gravity. If cystitis does not already exist, infection is 
practically sure to arise as soon as any amount of blood accumu- 
lates in the bladder. Haemorrhage may occur spontaneously, 
but is usually due to rough or careless instrumentation. The 
site of the bleeding is frequently the prostatic urethra, whose 
upper wall may be lined with distended varicose veins; but it 
most often arises from a point on the prostate which is habitually 
abraded by the introduction of a catheter. Occasionally it fol- 
lows upon the complete sudden evacuation of a distended blad- 
der from the relief of the intravesical pressure, being then in the 
nature of a general ooze from the mucous membrane. Calculous 
concretions are at times the exciting cause. In any case, the 
surest method of prevention is the continued use of the utmost 
gentleness in all manipulations. There is little doubt but that 
some cases exist where even the most skillful and gentle sur- 
geon cannot avoid provoking bleeding; but far more often it is 
directly due to culpable negligence or ignorance on the part of 
the person who attempts catheterization. The use of flexible 
or semi-flexible instruments is, as often before insisted upon, 
infinitely less harmful; and with their use haemorrhage from 
traumatism is least likely to occur; in rare cases, however, its 
recurrence is most readily obviated by recourse "oa metal catheter 
of large calibre and of an eminently fit curve — one that has been 
proved on previous occasions to enter with facility the bladder 
of this particular patient. The habit of employing metal cathe- 
ters is, however, a pernicious one, and only a surgeon with the 
greatest patience, the deftest and lightest hand, should feel him- 
self qualified to introduce one in cases such as this. 
11 p 



146 Prevention of Complications. 

As mentioned above, haematuria at times supervenes upon 
the sudden complete withdrawal of intravesical pressure; so 
that this is a reason against the indiscriminate emptying of 
chronically distended bladders, in addition to the danger of 
syncope and renal complications. 

Orchitis. — Orchitis is a complication to which some patients 
seem peculiarly liable, attacks recurring again and again, often- 
times from no apparent cause. Usually, however, the affection 
may be traced to infection from instrumentation, and is hence 
best prevented by limiting instrumentation as much as may be, 
or by avoiding it altogether, should this be practicable. Vesical 
and prostatic congestions should also be avoided by the methods 
already indicated on previous pages. 

Renal Complications and Uraemia. — Finally, nephritis, 
surgical kidneys, and uraemia must be prevented if possible 
from becoming complications of this already sufficiently trouble- 
some disease. 

Carefully selected food, plenty of fluid, and good bladder 
drainage are the most important means by which renal complica- 
tions may be avoided. Increase of renal pressure from damming 
up of the urine is one of the most unfailing causes of renal in- 
sufficiency; and is, of course, best prevented by securing a free 
outlet of urine from the bladder. For this purpose catheteri- 
zation will usually suffice; but when kidney breakdown is 
threatened from backward pressure which cannot be otherwise 
satisfactorily overcome, I think there can be no doubt that per- 
manent drainage of the bladder is indicated. If feasible, this 
should, of course, be procured through a permanently retained 
catheter; but should such a course not be possible, or should it 
have failed to avert the impending disaster, no hesitancy should 
be entertained about opening the bladder either suprapubically 
or through the perineum, and thus establishing an artificial ure- 
thra which will at once relieve the kidneys of injurious pres- 
sure. The choice between these two operations — suprapubic or 



Treatment of Cystitis. 147 

perineal — will be considered when discussing the treatment of 
complications. 

By thus relieving the backward pressure on the kidneys, and 
by preventing the developement of cystitis, the renal condition 
of these patients will be kept as nearly normal as possible; and 
when this is the case, little fear need be entertained of their being 
overwhelmed by ursemic symptoms ; but it is only by the strictest 
attention to the state of the urine on the one hand, and to that 
of the circulation on the other, that the kidneys can be main- 
tained in suitable condition. 

4. Treatment of Complications. 

Cystitis. — Cystitis is treated both locally and constitution- 
ally. The local treatment of cystitis may be considered under 
three headings: first, that by means of drugs acting through the 
kidneys; second, by means of irrigations of and injections into 
the bladder; and third, by means of drainage of the bladder. 

In no cases of cystitis should the constitutional treatment 
be neglected. If the inflammation be acute, and extremely pain- 
ful, rest in bed should be enjoined. The diet should be liquid 
or at most semisolid. Plenty of water should be taken. Hot 
sitz baths may prove beneficial, once or oftener in the course of 
twenty-four hours. The bowels should be well opened by mild 
cathartics or an enema. 

In mild cases these means alone may suffice to effect a cure, 
in the space of one or two days. Where the pain is severe and 
incessant, an opiate may be required; if morphine is contra- 
indicated by the state of the kidneys, or other affection, some 
milder hypnotic and analgesic may be used. The bromides and 
chloral in combination often act well; hyoscine, chloretone, sul- 
phonal, trional, or even paraldehyde, valerian, or asafcetida, may 
act beneficially. 

The condition of the urine is an all-important guide to further 
medicinal treatment. Acid urine, as previously mentioned, is 



148 Treatment of Complications. 

best neutralized by reducing the amount of sugar ingested, dilut- 
ing the urine by an increase in the quantity of fluid taken, and 
by certain of the alkaline waters. Where the urine is alkaline 
we may resort to the usual remedies, such as boric or benzoic 
acid, sodium benzoate, urotropin, etc. As an exceptionally use- 
ful urinary antiseptic I recommend salol. 

The aseptic and regular employment of the catheter, to re- 
move any residual urine, is frequently enough in itself to restore 
the bladder to its normal state. 

Combined with remedies such as the above, where the al- 
kalinity of the urine is not readily overcome, or where there is 
much pus or blood present, the bladder should be washed out. 
As a rule, the best solution is the decinormal solution of sodium 
chloride, which may readily be improvised by adding a teaspoon- 
ful of common table salt to a pint of sterile water. The proper 
solution consists of sodium chloride, one drachm and a half; 
sodium bicarbonate, fifteen grains; and sterile water, two pints. 
The use of drugs in the irrigation fluid is very rarely required; 
but boric acid solution (five or ten grains to the ounce) may at 
times clear up the urine sooner than the plain salt solution. 
Silver nitrate should never be employed except in cases of chronic 
cystitis; it may be commenced in the strength of one-quarter 
of a grain to the ounce, and if well borne, and if it appears that 
anything may be gained by such a course, the strength may 
be run up to five or even ten grains to the ounce. Great care 
should then be exercised that no part of so strong a solution come 
into contact with the urethra, which would probably be much 
irritated by it; but when acting on the transitional epithelium 
of a bladder whose walls are further protected by thick layers 
of mucus, and perhaps incrusted with salts, it does not seem 
probable that any harm can arise. Potassium permanganate, in 
the strength of 1 to 4000, is at times a useful drug. 

The temperature of any solution employed should be between 
90 and ioo° F.; and it should not negligently be permitted 



Irrigation of Bladder. 149 

to cool unduly during the process of irrigation. The position 
of the patient should usually be supine; but where the post- 
prostatic pouch is large and difficult to drain, the pelvis may 
advantageously be raised six or eight inches. 

The manner in which the bladder irrigations are given is 
important. It is very much better and more comfortable to the 
patient for them to be given through a soft-rubber or even a 
Mercier or English catheter; but where these cannot be intro- 
duced into the bladder, a metal catheter may readily be utilized 
by attaching a rubber tube to its outer extremity. Two methods 
of injection are used: the first by means of a syringe, holding 
at most one ounce, whose tip is carefully placed in the outer 
end of the catheter, which should be funnel-shaped for its recep- 
tion; the other method consists in attaching by means of glass 
and rubber tubing, a small funnel, holding about an ounce of 
water, into which the solution is poured, and from which it is 
allowed to run into the bladder by the force of gravity. Where 
a syringe is used for the injection no force whatever should be 
used in pushing the piston home ; indeed, it will usually be found 
that when the syringe is held vertically the piston sinks upon 
the contained fluid by its own weight. When the tubing and 
funnel apparatus is employed (and it is the more convenient when 
available), the funnel should never be raised to a height of more 
than two feet above the patient's bladder; usually the fluid will 
run easily at a height of a few inches. Whichever apparatus 
is used, not more than four ounces at the outside should be 
thrown into the bladder at any one time; when this quantity, 
or less if pain be caused, has been injected, it should be allowed 
to remain for ten or fifteen seconds, and then let out ; nor should 
the abdomen of the patient be kneaded too vigourously in an 
effort to hurry the process. It is a form of treatment that re- 
quires patience and time, and nothing is to be gained by haste. 
The bladder should not be refilled more than four or five times 
at the same sitting, and the operation should not be repeated, 
except in offensive cases, oftener than once in twenty-four hours. 



150 Treatment of Complications. 

Contrary to the general rule above stated, to the effect that 
not more than four ounces of fluid should be injected into the 
bladder at once, — which rule, however, I invariably adopt at 
the first irrigation, — I believe that much good may accrue from 
the passive but very gradual distention of chronically inflamed 
and contracted bladders. Thus I have seen patients who at 
the first sitting could not bear to have more than a single ounce 
thrown into their bladder at one time, subsequently, in the course 
of a few weeks, regain lost bladder capacity from that of one 
ounce until three or four and finally six or eight ounces could 
readily be retained ; the patients meanwhile experiencing a corre- 
sponding decrease in the frequency of urination. But the most 
gradual distention in the world should be practised: I am quite 
satisfied if I can establish a tolerance for a drachm or two 
additional at each sitting. 

In the practice of irrigating the bladder the attendant, and 
the patient as well, will often lose heart from the apparent slow- 
ness of progress in the relief of the cystitis; and many a time 
the surgeon will feel tempted to throw a large quantity of fluid 
into the bladder rapidly and with considerable force, in the 
effort to clear its cavity of accumulating mucus and blood clots 
by a process analogous to hydraulic mining ; but let him beware 
that he does not adopt such a practice! The sudden changes 
in form to which such methods would subject the bladder could 
but augment the inflammation, and might possibly cause the 
rupture of some of the vessels in its walls, burst some thin-walled 
sacculi, or carry infection into the ureters and on the way to 
the kidneys. The bladder itself might even be ruptured. It 
should be remembered that there is no expectation of mechanic- 
ally ridding the bladder of the products of inflammation and 
haemorrhages; we are not even operating by a variety of litho- 
lapaxy; and however pleased we may be when a quantity of 
debris is spontaneously evacuated through the catheter, we must 
not forget that our object is rather to prevent the persistence 



Permanent Catheter. 151 

or extension of the inflammation than to remove its products — 
we hope that these may dissolve and be passed by the urethra 
in the natural course of events. 

But in some cases these means do not suffice to arrest the 
cystitis; the introduction of a catheter is painful, difficult, or 
even impossible; the bladder irrigations give no relief; renal 
and uraemic complications impend, and urinary fever has already 
set in. Under these circumstances no further delay should be 
tolerated, but as soon as it is evident that ground is being lost 
the bladder should be drained. 

Of course, the simplest way by which this may be accom- 
plished is by permanently retaining a catheter, so that its eye 
projects just within the vesical cavity, and the urine is collected 
and discharged drop by drop, just as it is received from the 
ureters. It is important to have the catheter neither too far 
in, nor yet too far out of the bladder: in the former case its 
tip will cause great irritation of the vesical trigone, while in the 
latter the drainage will be very imperfect. To ensure its being 
in the correct situation, the catheter should first be fully intro- 
duced into the bladder until the urine flows in a steady stream; 
then it is to be slowly withdrawn until the urine stops running 
entirely, which it does when the eye enters the urethra; and then, 
finally, the catheter is to be pushed back again about three- 
eighths or half of an inch, until the urine escapes through it by 
drops. 

But it is an exceedingly difficult matter to keep a catheter 
permanently in the correct place. Many forms of self -retaining 
catheters have been invented, but in my opinion there is not one 
of them which is practically useful. The Nelaton catheter should, 
if possible, be that selected for the purpose, as being perfectly 
flexible it is less apt to cause irritation. Some degree of ure- 
thritis is nearly unavoidable, but with inflexible instruments 
not only is urethritis more likely, but every change in position 
of the patient is liable to wound the prostate or the bladder; 



15 2 Treatment of Complications. 

besides which it is very difficult to secure such a catheter in place. 
For rubber catheters the appliance shown in Plate lxiii (facing p. 
132) may be used, when it is at hand. This consists of a caoutchouc 
bridle attached at one end to the catheter at its point of entrance 
into the urethra, and fastening at the other around the body of the 
patient's penis. Where this is not available the catheter should 
be transfixed with a double ligature, through the loops of which, 
tied fairly close to the catheter on each side, strips of adhesive 
plaster are to be adjusted and fastened in a spiral and inter- 
lacing manner around the body of the penis. If a ligature can- 
not be procured in an emergency, the catheter may be transfixed 
with a safety-pin, and the adhesive plaster tied to that. Care 
should be taken that the attachment of the plaster to the catheter, 
in any case, is close to its point of entrance into the urethra, 
thus preventing the catheter from slipping too far in, as well 
as keeping it from falling out. Watson [245] has suggested an 
ingenious method by which a piece of rubber drainage tube, 
four or five inches long, and of slightly less calibre than the 
catheter employed (so as to grip it firmly), is passed over this 
latter, the drainage tube being split longitudinally into two 
halves up to within an inch of its outer extremity, and these 
lateral halves then being attached to the penis by adhesive plas- 
ter in the usual manner. Mercier and English catheters may 
be fastened in by means of a ligature or safety-pin as already 
described; while a metal instrument is best secured by passing 
the middle tails of a double T-bandage through the rings on 
each side of its shaft. 

The period during which the same catheter can be safely 
retained without changing varies much in different cases, and 
depends largely on the state of the urine; in some patients the 
catheter will within forty-eight hours become so incrusted with 
salts as to make its removal difficult. It appears that instru- 
ments made of webbing are more liable to the deposit of salts 
than the soft-rubber catheter, and this constitutes another ob- 



Cystotomy for Cystitis. 153 

jection to their use for such purposes. Even when no such 
trouble arises, the irritation to the urethra or bladder, or the pain 
experienced by the patient may render the removal of the catheter 
imperative within a comparatively short time. As a rule, one 
should not be left longer in place without changing than a week 
or ten days, unless surety exists that no crusts are forming. This 
question is best determined by previous experience with the same 
patient, although the condition of the urine may serve as a fairly 
reliable guide. 

When changed at suitable intervals permanent drainage by 
a catheter may be continued almost indefinitely. Thus Bazy 
[15] kept a Nelaton catheter in the bladder for eighteen months, 
the patient not being confined to bed. 

In some patients a catheter will not stay in place; it seems 
to work its way out either spontaneously, or slips from the ure- 
thra every time the patient changes his position in bed; while 
in others a catheter will stay securely in the bladder even when 
the patients are up and about, and leading a fairly active life. 

When from any cause the catheter cannot be retained in the 
urethra and drainage of the bladder still continues to be indi- 
cated, cystotomy must be done. 

This is a very much safer procedure than tapping the bladder 
and allowing the cannula to remain in place; and besides being 
safer, affords the surgeon the additional advantage of digital 
or even visual examination of the interior of the bladder and 
the prostate, as well as enabling him to proceed to the formation 
of an artificial urethra, should such an operation be indicated 
at that time. As a rule, suprapubic drainage is to be preferred; 
but in certain cases the perineal route is the better. By the 
suprapubic route the patient is subsequently less annoyed, no 
irritation of the sensitive prostatic urethra being produced by 
the drainage tube or catheter; a much more thorough examination 
of the bladder can be made ; and for subsequent radical operation 
it is the route of choice. Moreover, drainage by the suprapubic 



154 Treatment of Complications. 

wound is often better than by the perineal, since the fistula is 
shorter, the route more direct, and plugging of the tube much 
less likely. But where the patient is extremely weak, the opera- 
tion of suprapubic cystotomy is not usually advisable, offering, 
as it does, a mortality higher than perineal urethrotomy, both 
from the longer time required for its accomplishment, and from 
the additional shock entailed. Fortunately for the patients who 
have to submit to some form of cystotomy, those of them who 
have the severer grades of cystitis and in whom an operation of 
the gravity of even the suprapubic method would be dangerous, 
do not, usually, have prostates of very great size; and in these 
cases, therefore, the bladder is more conveniently, quickly, and 
safely reached through a median perineal urethrotomy than by 
the suprapubic operation. In patients, moreover, with very fat 
belly walls, the perineal route may be preferred. At the same 
time that drainage is instituted by the introduction of a tube 
through the prostatic urethra, it will sometimes be well, if the 
condition of the patient warrants the additional shock and the 
slight prolongation of the operation, to do a prostatotomy, or a 
digital dilatation of the prostatic urethra and vesical orifice, so 
as to ensure good drainage, and if possible produce a permanent 
cure of the obstruction. It is only in very exceptional cases that 
a radical removal of the prostate by either route should be at- 
tempted during an operation undertaken for the relief of the 
cystitis. Patients who are so gravely ill from cystitis as to de- 
mand a cutting operation for its relief, are in no condition to 
endure a prostatectomy. 

The technique of both suprapubic and perineal cystotomy 
will be described in a subsequent chapter. 

Retention of Urine. — (a) Acute Complete Retention of 
Urine. — As well said by Socin [212], this variety of urinary re- 
tention is in prostatics quite as serious an affection as strangu- 
lated hernia, and requires quite as prompt and efficacious treat- 
ment. The bladder may be very greatly distended by a small 



Retention of Urine. 155 

quantity of urine, as it may have been chronically contracted 
and inflamed for a long time. The pain is indescribably terrible, 
and instantly grows worse; not only is rupture threatened every 
moment, but the damming up of the urine into the ureters and 
kidneys renders urinary fever and uraemia likely; and even if 
rupture of the bladder does not occur, peritonitis by contiguity 
may soon develope. Since, moreover, the most usual cause of 
this form of retention is a mechanical obstruction caused by 
congestion of the prostatic urethra or vesical neck, which con- 
gestion grows worse every moment the retention is not relieved, 
it is evident how idle it is to resort to those remedies, such as 
opium and the hot bath, which are so successful at times in the 
treatment of acute urinary retention due to spasmodic or even 
to organic stricture. In patients of the latter class the retention 
is rarely absolute — usually a few drops trickle through the stric- 
tures now and again; and the bladder, moreover, is apt to be 
in a less unhealthy state, than where prostatic disease has existed 
for a long time. 

Hence the only rational treatment for this serious complica- 
tion is immediate relief by the catheter. It is very rarely indeed 
that a catheter cannot be introduced, provided no false passages 
have been made in careless and forcible attempts to gain en- 
trance to the bladder before the case is seen. The patient him- 
self, in his agony of pain and imperative desire for relief, may 
have produced false passages which even the most skillful cathe- 
terization will be unable to elude; or another practitioner with 
greater zeal than dexterity may likewise have rendered the ure- 
thra impassable. But in virgin urethras, which have not before 
had a catheter passed, and where no. strictures are present, a 
little persistence, and a good deal of patience and gentleness, 
will almost invariably accomplish the result desired. 

The soft-rubber catheter is to be tried first; this failing, the 
Mercier should be introduced, and its elbowed beak made to 
closely follow the roof of the urethra; should this also be met 



156 Treatment of Complications. 

by an insuperable obstruction, the English webbed catheter, 
moulded to a proper prostatic curve, may be tried, first alone, and 
then with its stylet. If passed with the stylet in its interior, the 
beak of the English catheter may usually be lifted over the 
raised vesical orifice of the urethra by partially withdrawing the 
stylet, as already described. When efforts thus conscientiously 
made also fail, metallic instruments may be tried; but I believe 
that a skillful surgeon will rarely succeed with these where he 
has failed with the English catheter mounted on the stylet. A 
hasty and impatient surgeon will no doubt often succeed in intro- 
ducing by force, perhaps by tunnelling the prostate, a metallic 
instrument into the bladder, where a little more dexterity and 
less force would have brought the same result to pass by means 
of a semiflexible instrument and without injury to the bladder, 
prostate, or urethra. 

Where strictures render the urethra difficult to catheterize, 
the usual manipulations employed in such cases should be em- 
ployed. These it is not necessary to describe in the present work. 
It seems scarcely requisite to add that wherever in genito-urinary 
surgery a catheter has been introduced only with the greatest 
difficulty, it should be allowed to remain permanently in the 
bladder until all acute symptoms have subsided. 

If, finally, no judicious efforts succeed in gaining entrance 
to the bladder through the urethra, the bladder must be tapped. 
The time during which urethral instrumentation should be per- 
sisted in will, of course, vary somewhat with different cases; 
but, as a rule, I do not think such attempts should be prolonged 
more than a half hour or forty-five minutes. Even this length 
of time will be injudicious where the retention has lasted for more 
than a few hours at most. 

While 1 recommend tapping of the bladder as the next step, 
I recognize that it must be only a temporary expedient; since 
it is very exceptional for the power of voluntary micturition 
through a urethra so much wounded and inflamed as these usually 



Retention of Urine. 157 

are, to return within any reasonable time; indeed, as already 
pointed out, where this acute retention is allowed to exist for 
any length of time, it is not impossible, indeed scarcely unusual, 
for chronic complete retention to follow from atony of the blad- 
der; so that where a competent surgeon is in attendance, and the 
surroundings make it suitable, it is best to do a suprapubic cyst- 
otomy at once, forming an artificial urethra by McGuire's method ; 
or if the bladder be very small and the abdominal walls thick, 
perineal drainage may be established, as indicated in the last 
section. 

But where no facilities for such operations exist, the bladder 
may be safely punctured suprapubically, and immediate danger 
averted, and the patient's pain temporarily relieved. This pro- 
cedure may be repeated a number of times without evil conse- 
quences, but, as long ago pointed out by Dittel [68], such treat- 
ment is really only a pastime for the surgeon, and is one which 
should be tolerated only until proper arrangements for cystotomy 
can be made. When the resort to cystotomy must be delayed, 
it may appear better to retain the cannula in the puncture than 
to reintroduce it every few hours. 

In cases of acute retention it is usually inadvisable to extend 
the palliative operation of cystotomy to the radical removal of 
the prostate; but this procedure is not so absolutely contrain- 
dicated as when the same operation is undertaken for drainage 
in cystitis. 

(b) Chronic Complete Retention oj Urine. — If atony of the 
bladder exists in cases of this variety, as can readily be deter- 
mined by the degree of force with which the urine is expelled 
through a catheter, it will be proper to make use of drainage 
of the bladder by a permanent catheter, in the hope that the 
chronic retention may be due to the atony alone, and not to mechan- 
ical obstruction by the enlarged prostate. By this method the blad- 
der walls may in the course of a few weeks recover their con- 
tractility, as evidenced by increasing force in any stream (whether 



158 Treatment of Complications. 

of urine or irrigation fluid) expelled through the catheter. If 
the atony be thus recovered from, it still remains to determine 
whether the mechanical prostatic obstruction is too great to be 
overcome by the restored bladder contractility. This question 
is readily answered in the affirmative if, on discontinuing the 
permanent drainage, the retention persists. In some exceptional 
cases it will have been found at the very outset that no atony of 
the bladder existed. Under either of these circumstances, then, 
— whether vesical atony never existed, or whether it be easily 
recovered from after relief of intravesical pressure by permanent 
drainage, — it is evident that the retention is due to mechanical 
prostatic obstruction. Hence the indication is to remove this by 
radical operation. 

If atony did exist, and yet was not recovered from after per- 
manent drainage, we are confronted with another problem: Will 
removal of the prostate be any more apt to relieve the vesical 
atony than was the drainage of the bladder through the catheter ? 
I think this question may fairly be answered in the affirmative; 
although I would hesitate to recommend radical treatment to a 
feeble patient whose catheter life was satisfactory to him. For 
there would still remain the risk that the radical operation would 
leave him no less dependent on the catheter than he previously 
was; but if his catheterism was painful, difficult, or unduly 
frequent, and the patient himself was not too old and feeble 
for any operation, I would be inclined to advise him to take 
the risk. 

(c) Chronic Incomplete Retention 0} Urine without Distention 
oj the Bladder. — Much of what was said in the early part of this 
chapter under the general heading of catheterism, applies to this 
complication. It is a nearly invariable accompaniment of every 
case of enlargement of the prostate; and I think there can be no 
question that the proper primary treatment is regular catheteri- 
zation. When this becomes unduly frequent — more than four 
or six times in the twenty-four hours; or exceptionally difficult 



Retention of Urine. 159 

or painful; or when the patient is not in a condition to carry 
out this plan of treatment intelligently, then removal of the cause 
of the residual urine is indicated. 

(d) Chronic Incomplete Retention 0} Urine with Distention of 
the Bladder. — For these patients the indications are first to restore 
the full measure of vesical contractility, and then to remove, if 
necessary, the obstructing prostate. But we are met at once 
with the objection that permanent catheterization, so effectual 
in reducing atony of the bladder in other cases, cannot be applied 
here, since the bladder is chronically distended, and such treat- 
ment would necessitate its sudden and complete evacuation. I 
am well aware that precisely this treatment in these or similar 
cases has been employed by so sagacious a surgeon as Cabot 
[41], of Boston; but his observations, though worthy of all con- 
sideration and most interesting, do not seem to me sufficiently 
numerous to overthrow the lessons of long clinical experience on 
the other side of the question. At least two of Dr. Cabot's patients 
suffered from fairly marked hematuria as soon as permanent 
drainage was instituted, the long-standing intravesical pressure 
being removed ; and one patient became ursemic on the day after 
the permanent catheter was introduced. Both were so fortunate, 
however, as to eventually recover from their severe renal symp- 
toms. Yet with the innumerable cases known for years, and still, 
I regret to say, occasionally seen, where the sudden withdrawal 
of urine from long overdistended bladders has caused surgical 
kidneys, uraemia, coma, and death, within a few days, I would 
myself be very chary in changing a plan of treatment founded 
on the dictates of experience for one unsupported, thus far at 
least, but by a handful of patients. 

Hence the proper treatment still to be advised for prostatics 
with overflow from retention, is to remove only a few — four to 
six — ounces of urine at a time, repeating this procedure every 
four or five hours as may be required, and thus gradually to 
empty the distended bladder in the course of two or three days. 



160 Treatment of Complications. 

Or, if desired, more urine may be withdrawn, and partially re- 
placed with saline or boric acid solution. 

The above plan of treatment presupposes that the urethra 
is freely open to catheterization. But this may not be the case, 
the urethra being obstructed by strictures or false passages. If 
a catheter can be introduced, but only with difficulty, the surgeon 
may try to clamp it, and leave it in situ, allowing a few ounces 
to run off by removing the clamp every couple of hours. But if no 
catheter of any kind can be introduced, a filiform bougie should 
be tried, as in the case of stricture unaccompanied by prostatic 
enlargement; when success attends these efforts, the filiform 
should be left in place, as the urine will satisfactorily and not too 
rapidly drain off along its track. If no kind of instrument can 
be introduced, I believe the proper course for the surgeon to 
pursue is to perform suprapubic cystotomy (McGuire's operation), 
evacuate the urine, staunch bleeding from the mucous mem- 
brane of the bladder by the hot douche ; and take the usual con- 
stitutional precautions against the developement of surgical kid- 
ney and uraemia. 

Aspiration or tapping of the bladder may be thought by some 
a preferable course, only a few ounces being removed each time, 
and the operation being repeated innumerable times; but such 
a plan of treatment admits of no hope to the patient save the 
classical "meditation upon death"; for it is the most improbable 
thing in the world that the urethra will again become open to 
instrumentation before the " meditation' ' of the patient has passed 
into the reality. 

Perineal section — by which I mean external perineal urethrot- 
omy without a guide — which would be the only perineal pro- 
cedure save Cock's operation available under such circumstances, 
is a difficult operation at the best of times, and its difficulties are 
not lightened by the existence of false passages and an enlarged 
prostate. Moreover, in patients with retention and overflow the 
prostate is apt to be of considerable size, and entrance to the 
bladder from the perineum would be by no means so easy as from 



Calculus. 161 

above the pubis; nor would the facilities for douching the blad- 
der or even packing its cavity, in case the haemorrhage was pro- 
fuse, be so ample as by the high route. Cock's operation — 
tapping the urethra at the apex of the prostate — is open to the 
same objections, except those concerning the difficulty of per- 
formance. 

Calculus. — The most generally accepted plan of treatment 
for calculus complicating enlargement of the prostate is supra- 
pubic lithotomy with prostatectomy in suitable cases as well; 
and it is that which I have myself employed, and which I think 
is still to be recommended. Not a few successes have been 
reported from operations by litholapaxy, and in several instances 
this operation has been followed immediately or after a few weeks 
by Bottini's galvanocaustic prostatotomy. (Chismore [46], Willy 
Meyer [162], Young [260], etc.) But although I have no doubt that 
in the hands of those surgeons habituated to such manipulations the 
outcome may be perfectly successful in certain cases, yet there 
remain other patients in whom the intravesical projection of the 
prostate makes this procedure out of the question, as of course 
it would also be where the urethra was not open freely to instru- 
mentation. 

Phosphatic calculus being merely a symptom of the enlarged 
prostate it is futile to expect removal of the calculus alone to 
effect permanent relief. (Keyes [133].) 

In few words my position may be stated thus: that in those 
cases in which I consider the Bottini operation advisable I would 
not be adverse to doing litholapaxy ; but as will be seen in subse- 
quent pages I prefer to limit the Bottini operation to very excep- 
tional cases. 

Orchitis is to be treated as when arising from other causes. 
Instrumentation should also be discontinued. 

Haemorrhage into the bladder is best treated by hot irrigations, 
and permanent drainage, which may be instituted by means of 
a suprapubic wound if necessary. 



162 Treatment of Complications. 

Renal Complications and Uraemia. — For these complica- 
tions the treatment in patients with enlargement of the prostate 
does not differ materially from that habitually employed in other 
cases. Good bladder drainage is, however, more imperative, 
as well as, unfortunately, more difficult to secure. The per- 
manently retained catheter, or suprapubic or perineal drainage, 
may be employed, according to the principles already laid down. 
If polyuria is a distressing feature it may be partially relieved 
by reducing the amount of fluid ingested, and by promoting per- 
spiration. Care should be exercised that atony of the bladder 
from overdistention does not arise. 

In the later stages of renal affections, when the urine becomes 
scanty or suppressed, the usual increase in ingested fluid should 
be prescribed ; and great advantage may be derived from the use 
of saline solution by the bowel. A pint is readily absorbed from 
the colon in the course of an hour or so ; the temperature should 
be over ioo° F. In sudden emergencies intravenous infusion, 
of the decinormal salt solution may be employed, it being rarely 
advisable to give more than two or three pints at once by this 
method. This fluid is probably absorbed nearly as rapidly 
from the bowel as when given intravenously, and certainly more 
rapidly than when administered by hypodermoclysis. 

The steam bath should be employed in case of uraemia, or 
when it is not available, pilocarpine should be given hypoder- 
matically. The tendency which this drug is said to possess of pro- 
ducing or at any rate favouring oedema of the lungs is against 
it; but in so great an emergency as uraemic coma this risk may 
be taken. The hydrochlorate is the best salt, and is prescribed 
in doses of one-eighth to one-quarter of a grain. Digitalis is of 
use in increasing the action of the kidneys and heart. Sparteine 
is also an efficient diuretic. The sulphate is employed in doses 
of one-half to two grains. 

Dry cups applied over the loins may sometimes be of service. 

Much interest has recently been aroused by the proposal of 



Nephritis and Uraemia. 163 

Dr. Cabot [41], of Boston, to treat patients with surgical kidneys 
by means of drainage of the bladder. This is really a revival of 
Mr. Reginald Harrison's [114] method (1887) of treating sup- 
purative nephritis by means of perineal cystotomy; this pro- 
cedure possesses the advantage, as pointed out by Mr. Harrison, 
of being equally applicable whether one or both kidneys are 
affected, or whether it is uncertain which of the two kidneys is 
diseased. It was a method commended also by Dr. F. S. Wat- 
son [245], of Boston, in 1895. But Cabot has called renewed 
attention to the subject, and, as already remarked, has reported 
six very interesting observations. In his patients, treated by 
permanent catheterization, there was in all marked improve- 
ment evident as soon as the backward renal pressure was re- 
lieved : the distressing polyuria was reduced from sixty or seventy 
ounces to nearly normal, and at the same time the specific gravity 
increased from 1005 to 1012 and 1015. 

Dr. Cabot says he is well aware that this procedure is no 
new therapeutic measure, but he thinks its applicability to renal 
disease has not hitherto been sufficiently appreciated, although 
the good effects of Edebohls's operation in relieving renal tension 
are well known to the profession. For present purposes he took 
it for granted "that a patient with obstructive disease of the 
prostate and dilated bladder may be regarded as having some 
degree of interstitial nephritis if the urine is abundant and of 
very low specific gravity. If such a patient is suffering from 
anorexia, nausea, and dry mouth, either with or without psychical 
disturbances, these are to be looked upon as symptoms of uraemia 
due to this interstitial nephritis. If, in addition to these symp- 
toms, he has a high fever and the urine contains pus, it is to be 
regarded as probable that he has pyelonephritis." The follow- 
ing summary of the results obtained is worthy of careful atten- 
tion: 

The first patient, a man of sixty-seven years, after using the 
catheter for some months, there being over twelve ounces of 



164 Treatment of Complications. 

residual urine, was taken seriously ill, with a temperature of 
103 F. — apparently commencing pyelonephritis. By constant 
drainage the amount of urine was in the course of some weeks 
reduced from sixty or seventy ounces to less than fifty ounces 
daily, while its specific gravity increased from 1007 to 1023. 
Intermittent catheterization was then resumed. 

In the second patient there was anorexia, dry mouth, much 
nausea, and marked somnolence. By constant drainage the 
return to normal was remarkably rapid. 

The third patient, in much the same general state, had fever 
as well. His bladder was distended nearly to the umbilicus. 
Thirty-seven ounces of urine of very low specific gravity were 
withdrawn, and by continuous drainage the patient's health was 
after a period of two months practically restored, although the 
quantity of urine remained at seventy or ninety ounces daily, 
and its specific gravity did not rise above 1008. 

The fourth patient, aged seventy-two years, had suffered for 
several years with crebruria, there being about twelve ounces 
of residual urine. A resort to catheterization once or twice 
daily produced in about two weeks' time symptoms of commenc- 
ing pyelonephritis. Constant drainage was then begun. Haema- 
turia developed, and the next day the patient became uraemic. 
Under proper constitutional treatment all unfavourable symptoms 
disappeared, but it was not until the seventy-ninth day that inter- 
mittent catheterization could be substituted for continuous drain- 
age. His daily amount of urine remained at about one hundred 
ounces, of specific gravity 1012 to 1015. 

In the fifth patient the chronically obstructed bladder con- 
tained forty ounces of urine. Constant drainage, while it pro- 
duced transient haematuria, relieved the delirium, fever, and 
thirst. Three weeks later intermittent catheterization was be- 
gun. The urine at last report, over a year after the acute attack 
noted above, was forty to sixty ounces daily in quantity, of 
specific gravity 1017. 



Nephritis and Uraemia. 165 

The last patient reported was in the early stages of chronic 
nephritis, with polyuria amounting to eight pints (128 ounces) 
in the twenty-four hours. When chronic retention set in, this 
amount was reduced to six pints, of specific gravity 1005. Con- 
stant drainage was instituted, and in one day the amount of urine 
drained off reached sixteen pints (256 ounces). This was grad- 
ually reduced to six pints, and finally to four pints (64 ounces) 
daily, while the specific gravity rose to 10 12 and 1015. 

It is thus seen what a very valuable means of treatment 
permanent catheterization in these cases may become: it will 
bring back some patients from the verge of the grave, and enable 
them sometimes to return to a life of intermittent catheterization 
(when they decline operative interference) in the enjoyment of 
excellent health. 



CHAPTER X. 

LOCAL PALLIATIVE TREATMENT, INCLUDING URINARY FIS- 
TULA, THE BOTTINI OPERATION, AND CASTRATION. 

I. Urinary Fistula. — Some of the indications for this form 
of treatment have already been considered — cystitis, unrelieved 
by irrigations, catheterism, or permanent drainage by the catheter; 
the various forms of chronic retention of urine; exceptionally 
for acute retention, when passing into the chronic variety; and 
as a preventative of Bright's disease and other renal affections. 
Some surgeons have been so pleased with the effect produced 
on the long-standing cystitis, and with the life of comparative 
ease enjoyed by patients possessing an artificial channel for 
urination, that they have proposed stopping all operative treat- 
ment at this stage, and leaving their patients for the remainder 
of their lives with artificial urethras. That such a course is not 
in some cases an eminently proper procedure, no one would 
be so injudicious as to assert; but that the surgeon should rest 
content with it for routine treatment I think indefensible in the 
extreme. As well might one argue for the permanence of a gas- 
tric fistula in the presence of stricture of the oesophagus, of a 
jejunal fistula with pyloric obstruction, or of a faecal fistula 
with disease of the colon or rectum; and be unwilling to admit 
that in selected cases it was not only justifiable but absolutely 
imperative to proceed to the cure of the oesophageal stricture, 
the evasion of the pyloric stenosis, and the removal of the dis- 
eased colon or rectum, with re-establishment of the natural chan- 
nel of excretion. 

It is for these reasons, therefore, that the treatment by urinary 
fistula is considered merely a palliative remedy, to be employed 
only where it is not proper to resort to radical treatment; chiefly 

166 



Urinary Fistula. 167 

as an emergency operation ; very rarely as the final form of treat- 
ment. 

As mentioned before, my preference is for suprapubic cyst- 
otomy, with the establishment of an artificial urethra by the 
method of McGuire [155]. The reasons already given for this 
preference may be reiterated and enlarged upon in the present 
chapter. 

In the first place, the results to the patient are more satis- 
factory than when a perineal fistula is established. When the 
artificial urethra remains as a permanent thing, the convenience 
and comfort of the patient are matters of considerable impor- 
tance. Incontinence is rarely a sequel of the suprapubic opera- 
tion; and when it does occur, is very readily obviated by the 
use of an obturator in the new channel. Where the artificial urethra 
is in the perineum incontinence is both more likely, and when it 
does exist no obturator will keep urine from dribbling out; and 
the wearing of a urinal becomes necessary, with the retention 
of a tube in the perineal fistula to conduct the urine to its recep- 
tacle; since were no tube retained the urine would trickle down 
the thighs. 

The mode of making urine, moreover, is usually more con- 
venient through a suprapubic than through a perineal fistula. 
In the former case, if the patient is not able to expel his urine 
in a parabolic stream, much as in the normal state, a soft-rubber 
catheter is very readily dropped into the bladder, and with a 
slight primary contraction the remainder of the urine is evacuated 
by syphonage. Patients with perineal fistulae are very seldom 
satisfied with their method of urinating, which I have heard 
them compare to that of a cow. 

By the suprapubic route the inflamed vesical neck is not 
injured, either at the time of operation, or in the subsequent 
treatment of the patient. Better opportunity is afforded for 
examination of the interior of the bladder, and for the evacuation 
of calculi, pus, mucus, and blood clots. 



168 Local Treatment. 

The route for drainage of the bladder and for post-operative 
irrigation is more direct; larger tubes are used for drainage, 
and as a consequence the drainage is better, the tubes are less 
likely to become obstructed or kinked; and the convalescence 
is pleasanter for the patient. 

The prostate is usually so large as to make access to the 
bladder from the perineum difficult, and as to render drainage 
of the post-prostatic pouch by this route ineffectual. The blad- 
der is usually dilated and carried well above the symphysis, so 
that it is much more readily reached by the high operation. 

But there are certain cases, few in number I acknowledge, 
but still worthy of consideration, where bladder drainage is in- 
dicated, where it cannot be obtained satisfactorily through the 
urethra, and yet where the bladder is small, thick, contracted, 
and very difficult of access by the hypogastric route. In these 
patients, as a rule, the prostate is small and sclerosed, and does 
not obstruct urination so much by its size, as by rendering the 
neck of the bladder immobile. In cases such as these, the ad- 
vantages possessed by the perineal route are obvious. 

It appears to me, then, that cystotomy for enlargement of the 
prostate is a very valuable operation, not lightly to be discarded. 
It is a step between catheterism and prostatectomy; and while 
it should, on the one hand, never be undertaken without the 
hope of being able to cure the patient at a later time by the 
radical operation, it should yet always be done in such a manner 
that, if further interference should subsequently seem inadvis- 
able, the patient will nevertheless recover with an artificial ure- 
thra worthy of the name. 

When employed only in selected cases the operation of form- 
ing an artificial urethra is attended by a very slight mortality. 
I am not aware that statistics of the perineal operation have 
been published, but the following table gives the results of Mc- 
Guire's operation (in cases presumably selected) in the hands 
of various operators: 



PLATE LXVI, 




Suprapubic Fistula Established by McGuire's Method, showing the 

Obturator. 



Urinary Fistula. 169 

Operator. Cases. Deaths. pScSt! 

Wiesinger [251] 24 o 0.00 

Bjorn Hodernus [24] 20 o 0.00 

Lagoutte [141] 21 4 19.00 

Poncet and Delore [195] 39 2 5.12 

McGuire [156] 39 2 5.12 

Horwitz [126] 33 o 0.00 

Total 176 8 4.54 

Poncet and Delore [195] have called attention to the very 
much greater mortality which obtains among patients whose 
bladders are already seriously infected. Others they term the 
mechanical; but among the infected cases these authors record 
forty-two patients treated in this manner by Lagoutte, of whom 
fifteen died, a mortality of 35.7 per cent.; while of seventy-five 
such operations in their own hands, no less than twenty-nine 
terminated fatally, a mortality of 38.7 per cent. Watson [245] 
has recently published the results of 146 drainage operations by 
various surgeons, not classed as suprapubic or perineal, but prob- 
ably including examples of both operations; of these, forty-nine 
terminated fatally, a mortality of 33.5 per cent. This high 
death-rate is probably to be explained in the same way as that 
which attends the infected cases of Poncet and Delore: because 
in these cases the operation is undertaken as a last resort, some 
of the patients being even moribund at the time, and the surgeon 
adopting this form of treatment as a forlorn hope, or as a means 
of producing euthanasia. 

Technique 0} the Establishment of an Artificial Urethra by 
Suprapubic Cystotomy. — This operation may readily be performed 
under local anaesthesia with cocaine, if desired; but where the 
condition of the patient does not contraindicate a general anaes- 
thetic, I prefer to use ether. 

The bladder should contain from three to six ounces of fluid. 
Where the urethra is impassable the bladder will be distended 
by its retained urine. I do not distend the rectum, as I consider 
that this is unnecessary and that it exposes the patient to use- 



170 Local Treatment. 

less danger; instead, I have the patient placed in a moderate 
Trendelenburg position, the pelvis being elevated from eight to 
ten inches. When the patient is in the Trendelenburg position, 
indeed, it is scarcely necessary to have the bladder distended in 
any manner, as it becomes sufficiently accessible, merely from 
the falling away of the abdominal contents. 

Distention of the bladder with air is employed by some sur- 
geons as a preliminary to suprapubic cystotomy, and for the per- 
formance of the Bottini operation. Although it appears to be 
preferable to distention with water for the latter operation, yet 
it is not in any case devoid of danger. In a patient of my own, in- 
jection of air into the bladder produced subcutaneous emphysema 
of the penis; and in the hands of another surgeon I have seen 
emphysema of the belly wall as a consequence of this procedure. 
It has even been thought possible that injurious consequences 
to the ureters and kidneys might ensue. (See W. Meyer [164].) 

The surgeon standing on the patient's right side, an incision 
about two inches long is made just above the pubis, to one side 
or the other of the linea alba, separating the fibres of the rectus 
muscle longitudinally. This lateral position of the incision de- 
creases the chances of subsequent incontinence, as the muscular 
fibres keep the wound closed except when separated by the intro- 
duction of a tube. 

The lower end of the incision should touch the symphysis 
pubis, and at the upper end the incision should grow progres- 
sively shorter as it is deepened through the abdominal walls. No 
vessels or nerves large enough to be named are divided, and haemor- 
rhage is insignificant. 

The space of Retzius is now opened. The fat and cellular 
tissue which fills it should be carefully separated in the same 
line as the abdominal incision, deviating neither to the right nor 
left. Any large veins should be avoided. If cut, however, they 
will cease to bleed when the bladder is opened, but can be ligated 
if necessary. It is usually more expeditious, as well as produc- 



PLATE LXVII. 




i. Stevenson's suprapubic tube. 2. Senn's sigmoid tube for suprapubic fistuh 



McGuire's Operation. 171 

tive of less disturbance to the parts, to dissect through this tissue 
with blunt-pointed scissors. Tearing it apart with the handle 
of the scalpel or the fingers contuses it so that it is more liable to 
infection from the urine. 

The bladder is readily recognized by its bluish appearance 
and its consistency. The reflection of peritoneum is seldom seen 
at all. If in the way, it is readily separated from the bladder 
by blunt dissection. 

When the bladder is reached, a silk or silkworm-gut suture 
should be passed through the outer layers of its wall about a 
quarter of an inch on each side of the line of the incision. These 
are to be used as tractors, and may be looped, or caught with 
haemostatic forceps. They are not designed to remain after the op- 
eration, nor to secure the bladder to the abdominal wall. Where 
the belly wall is thick, and the introduction of these sutures difficult, 
a single suture will suffice ; this may then be placed in the line of 
the incision, at its upper limit ; or a tenaculum may be used to 
steady the bladder, as originally recommended by McGuire [155]. 

The bladder being thus secured it should be opened at a 
point not above the upper margin of the pubis, the edge of the 
knife being turned downwards. The incision in its wall should 
be longitudinal, and amply large to admit the surgeon's index 
finger. Some of these bladders have very tough and thick walls, 
and the opening does not dilate as the finger is introduced. The 
finger should follow the knife into the bladder before much of 
the intravesical fluid has escaped, as it will thus be able to gain 
a much more accurate idea of the interior of the bladder than 
when this viscus has become empty. 

Unless the prostate has been injured previously or during the 
operation, haemorrhage from the interior of the bladder is not apt 
to be severe. It is usually easily controlled by douching the blad- 
der with hot water or salt solution. In extreme cases the cavity of 
the bladder may be stuffed with iodoform gauze, which may be 
pressed firmly against any bleeding point that can be discovered. 



172 Local Treatment. 

Any calculi present should then be removed, and blood clots, 
inspissated mucus, etc., washed out. For such purposes it may 
become necessary to enlarge the wound in the wall of the bladder; 
but it is well to avoid this when possible. It will very rarely be 
proper to prolong this operation into even a partial prostatectomy. 

A good-sized rubber catheter — about number 35 to 40 of the 
French scale — or a drainage tube, should then be inserted into 
the bladder, down to but not touching the post-prostatic pouch. 
A double tube is necessary only when vesical catarrh is pro- 
nounced. If the tube is carried down too far, its end may be- 
come hermetically sealed by the bladder contracting on it. It 
is therefore well to have a tube with a lateral opening, as well as 
to avoid inserting it too far. 

The retention sutures may then be removed, and the bladder 
in sinking back into the pelvis will carry the vesical opening 
of the new urethra even lower than before. The tube may have 
to be inserted more deeply at this stage of the operation. 

The lower angle of the incision in the anterior sheath of the 
rectus should then be approximated with a couple of interrupted 
sutures of chromicized catgut or silk; and both angles of the 
skin wound sutured, so as, however, to allow the catheter to emerge 
higher than the middle of the original incision. In his later 
operations McGuire [156] employed no sutures at all, relying on 
careful placing of the tube to secure an artificial urethra of the 
desired obliquity. If the wound in the bladder have been en- 
larged beyond that requisite to admit the finger, it will of course 
be proper to apply a couple of sutures in that position. This 
may best be done in such a manner as to invert the bladder wall into 
the cavity of this viscus, thus producing a wound which is least 
likely to result in subsequent incontinence of urine. 

The tube should be sutured to the skin on one side, to pre- 
vent it slipping in or out. A copious dressing of sterile gauze and 
absorbent cotton is then applied; and the tube connected by 
rubber tubing with a urinal beside the bed. 



PLATE LXVI1 




Stevenson's Suprapubic Tube in Place, with Urinal Attached. — {After DaCosta.) 



Suprapubic Fistula. 173 

The urine should be kept scrupulously acid, both before and 
after the operation. For this purpose Dr. McGuire [155] thought 
nothing so efficacious as citric acid in the form of lemonade. 

The patient may be allowed to sit up in bed as soon after 
the operation as he feels able; and may be let out of bed, as a 
rule, on the fourth or fifth day. 

If the drainage tube causes much annoyance, it may be safely 
removed within six or eight hours after the operation; by which 
time the wound will have become thoroughly " glazed." The 
free discharge of urine through the suprapubic opening may be 
relied upon to keep the wound from closing; but it is better to 
leave the tube in the bladder for at least forty-eight hours after 
the operation. If it has, however, been removed earlier to re- 
lieve the patient, it can usually be replaced after the first day 
or two, if necessary, without producing renewed irritation. 

Where the urethral obstruction is marked there is no likeli- 
hood of the artificial urethra closing; but where this tendency 
is observed, a good-sized tube should be constantly worn in the 
wound. 

Where continuous drainage, as in cases of bad cystitis, is 
desired, one of the many forms of tubes with urinals attached may 
be employed, so that the patient will not be confined to bed. 
If the vesical irritability is great, and the prostate encroaches 
much on the cavity of the bladder, Senn's sigmoid drainage tube 
(Plates lxvti and lxix) is probably the best variety. Stevenson's 
tube is another convenient form (Plates lxvii and lxviii). 

Where constant drainage is not required, but where the blad- 
der is able to retain a certain quantity of urine and needs only 
occasional evacuation, McGuire' s obturator (Plate lxvi) may be 
worn in the wound ; although in some cases no involuntary leak- 
age will occur even without this appliance, except when the level 
of the urine within the bladder becomes higher than the external 
opening of the artificial urethra, or when the patient assumes 
the supine position. On removing the obturator the patient 



174 Local Treatment. 

may be able to empty the bladder by voluntary contraction; but 
where the vesical atony is extreme the introduction of a catheter 
through the suprapubic wound will be necessary. 

Technique of Perineal Prostatotomy for Treatment of Enlarged 
Prostate by Perineal Fistula. — This operation is even more readily 
performed under local cocaine anaesthesia than is the suprapubic ; 
but where there is no objection to a general anaesthetic, ether 
is to be preferred. 

It is well for the bladder to contain a few ounces of fluid. 
An ordinary grooved staff should then be introduced into the 
urethra, and the patient brought into the lithotomy position. I 
do not use stirrups to hold the legs, but have assistants support 
them in the desired position. It has always seemed to me a 
risk to flex the stiffened joints and atheromatous arteries of these 
decrepit old men to the extent necessitated by the employment 
of the usual forms of retention apparatus. 

The surgeon then opens the membranous urethra in the usual 
way, by an incision about an inch in length, in the median line 
of the perineum, passing through the perineal centre. When 
the point of the knife is lodged in the groove of the staff, it is 
run forward into the bladder, dividing the anterior part of the 
floor of the prostatic urethra. When the bladder is entered, 
the left index finger of the surgeon should follow the track of 
the knife; and when the finger also has reached the bladder 
the staff may be removed. As the knife is withdrawn it should 
be made to incise the vesical neck, the prostate, and the pros- 
tatic urethra. The left index finger of the surgeon, which has 
never been removed from the bladder, may now determine by 
palpation the state of affairs in the interior of the bladder. Any 
calculi present may be removed with forceps or scoop, secundum 
artem; and the interior of the bladder douched through the peri- 
neal wound, to evacuate blood clots, mucus, etc. At times haemor- 
rhage may be severe, and the wound may have to be plugged 
around a tube. 



PLATE LXIX, 




Senn's Sigmoid Catheter in Place with Tube Attached for Constant Drain- 
age into CJrtnal. — {After DaCosta.) 



Perineal Fistula. 175 

The left index finger should not leave the bladder until the 
permanent drainage tube is in place. In some cases it is well 
to further dilate the vesical orifice of the urethra by digital divul- 
sion, with the two index fingers; or large-sized steel sounds 
may be introduced through the perineal wound, and the urethra 
be thus dilated. 

The drainage catheter or tube, which should be as large as 
possible, and metal by preference, is then to be fixed in place. 
Its inner opening should be neither too far in, nor yet too far 
out. This may be determined in accordance with the principles 
given at page 151, when speaking of the fixation of permanent 
catheters in the urethra. If no metal or hard-rubber tube of 
the variety to be presently described is available, an ordinary 
large-sized English catheter or even a rubber drainage tube, 
without perforations, may be employed. It is to be remembered 
that the object of the operation now under discussion is to es- 
tablish a more or less permanent perineal fistula, so the neces- 
sity of using a firm tube of large calibre is readily appreciated. 
The metal tubes intended for this purpose are provided with 
means of attachment by which they may be retained in the 
wound without trouble ; but the webbed or rubber catheters must 
be fastened by a suture to both margins of the skin wound. 

When the patient has been returned to bed, the perineal drain 
should be connected by glass and rubber tubing with a urinal 
hung beside the bed. If the grade of cystitis is severe, and the 
urine offensive, it is well for the end of the tube hanging in the 
urinal to dip into some antiseptic or deodorant solution. Of 
course, in reckoning the amount of urine drained off from the 
bladder the amount of solution already in the urinal must be 
subtracted. If the tube becomes clogged, or fails to drain for 
any reason, it should be flushed out with boric acid solution by 
means of a syringe, which is readily applied to the outer end 
of the perineal tube by disconnecting the glass and rubber tubing 
which passes to the urinal. This fluid for injection should not 



176 Local Treatment. 

be more than lukewarm if it is desired to dislodge clots of blood, 
on account of the coagulating powers of hot solutions. It is 
very rarely advisable, and, except in skillful hands, rather dan- 
gerous, to attempt to dislodge obstructions in the perineal drain 
by means of a probe or stylet. 

The patient should stay in bed for at least six to eight days, 
the quiet being advisable so as to permit the fistula to heal soundly 
around the tube, before any occasion arises for its removal. 

As before mentioned, if this operation is done in an emergency, 
as when it is required for retention of urine, a large-sized English 
catheter or a Nelaton catheter may be used for the perineal drain ; 
but where possible it is better to have a metal or hard-rubber 
tube, which ensure better drainage and a more permanent fis- 
tula, because of their unyielding quality. Watson's perineal tubes 
[242] will be found very satisfactory (Plate lxx) ; and where the 
urine is ammoniacal and the tube is prone to become encrusted 
with phosphates, the appliance invented by Dr. Owens [186], 
and resembling in construction a tracheotomy tube, will be of 
value. Owens' s tube, consisting as it does of two distinct parts, 
admits of the daily removal of the inner tube for cleansing, 
without disturbing the outer tube. Where a single tube of metal, 
webbing, or rubber is employed, it should be removed and 
cleansed once in a week or ten days, the intervals depending 
upon the state of the urine. English catheters must usually be 
discarded after a week's use; rubber tubes may remain good 
for several weeks with proper care; but metal tubes will prac- 
tically never wear out. 

After from six to twelve weeks the perineal tube may be 
permanently removed. If urethral obstruction still exists, the 
fistula will remain; but, unless incontinence of urine follows 
the operation, no tube need be worn, as urine will escape only 
at stated intervals, controlled voluntarily. If incontinence, how- 
ever, is present, a tube with urinal attached must be worn con- 
stantly. 

2. The Bottini Operation. — It seems uncertain whether the 



PLATE LXX. 





i. Owens's perineal tube. 2. Watson's perineal tube. 



The Bottini Operation. 177 

original aim of the inventor of this method of operating was 
merely to remove at the time of the operation, as Mercier [159] 
and others with cutting instruments had done before him, enough 
of the prostatic obstruction to cause a subsidence of the symp- 
toms; or whether, as has been claimed by some, his design was 
to cause shrinkage and decrease in bulk of the whole gland dur- 
ing the process of cicatrization and contraction which neces- 
sarily ensues upon the cauterization. Whichever was the original 
aim, there can be no doubt that at the present day the results 
are sought to be obtained through the process of cicatrization 
and contraction very much more than through actual burning 
away of barriers. 

This fact gives us a clue to two of the chief characteristics 
of the Bottini operation — the imperfection of the immediate 
result, and the uncertainty as to the ultimate effect. It depends 
very largely on the individual prostate whether the burning in 
it of grooves of certain (or uncertain) size will cause enough 
contraction during cicatrization to relieve the obstruction, will 
have no effect at all, or will result in such distortion of the part 
as to leave the patient worse off than before the operation. And 
at the present day it next to never happens that the amount 
of prostatic tissue oxidized by the cautery during the operation 
is sufficient to immediately relieve the obstruction, without the 
action of the subsequent cicatricial contraction. 

On account of these shortcomings, and of other objections 
which will be mentioned presently, many surgeons have denied 
that this operation has any place at all in surgery; while there are, 
on the other hand, quite as enthusiastic surgeons who deny that 
any other operation is worthy of trial in the treatment of pro- 
statics. Those surgeons who are open to reason, it seems to me, 
will take a middle course, and while recognizing the insuperable 
objections to this form of treatment as the exclusive operation 
for prostatic enlargement, will nevertheless admit its applicability 
to a limited — an extremely limited — number of cases. 
13 P 



178 Local Treatment. 

Yet in spite of this wide divergence of opinion among sur- 
geons, there are, fortunately, a few facts which are admitted to 
be true by both sides in this controversy. First and foremost 
among these is that the mortality of the operation is low. Wat- 
son [244] has recently summarized the results of 1086 Bottini 
operations performed by various surgeons. Among these there 
were 69 deaths, being a mortality rate of 6.3 per cent. Freuden- 
berg [82], in 1900, collected 753 operations by this method, 44 
of which, or 5.8 per cent., terminated fatally. This mortality 
rate, however, seems to me to be below the truth. It is less than 
the average obtained by seven of the most skillful operators in 
our own country and Germany, as will be seen presently, and is 
decidedly less than that which the general surgeon who does 
the operation only occasionally can hope to secure. Burckhardt 
[39] collected 75 recent cases, including his own, the average 
death-rate being over ten per cent., as seen in the following table: 

Operator. Cases. Deaths. 

Verhoogen n 3 

Pisani 1 o 

Czerny 10 1 

Konig 19 2 

Roth 6 o 

E. Burckhardt 28 2 

- 75 8 

10.66 % mortality. 

Another fact generally admitted both by those favouring and 
by those opposed to the Bottini operation, is that the mortality 
rate grows progressively less as the number of cases operated 
upon by any one surgeon increases. That is to say, that in- 
dividual dexterity and practice have much to do with the success 
of the operator. What Keyes [133] said in regard to litholapaxy 
may be applied with equal force to this operation : that a general 
surgeon will perform a cystotomy, a lithotomy, a prostatectomy, 
as well as any other cutting operation, because these operations 
are a part of general surgery; but that he will not perform a Bot- 



The Bottini Operation. 179 

tini operation as well the fifth time he does it as he will the fiftieth ; 
whereas there will be no difference between his fifth and fiftieth 
lithotomy, either in its performance or its result. And I have 
great regard for a surgeon like Finney [79], of Baltimore, who 
expressed such Hallerian diffidence, that, as he said, he did not 
"dare" to perform this operation himself, when he saw such 
excellent results from it in the hands of one of his colleagues. 
But even in the hands of those who are acknowledged to be most 
skillful in its performance, the aggregate of deaths does not fall 
below the average mortality as given by Freudenberg and Wat- 
son, as a glance at the following compilation of late statistics 
will show: 

Mortality 
Operator. Cases. Deaths. Per Cent. 

Bangs [12] 34 3 8.8 

Burckhardt [39] 28 2 7.1 

Freudenberg [84] 51 4 7.8 

Horwitz[i26] 95 3 3.1 

W.Meyer [165] 59 7 11.8 

Young [260] 41 3 7.1 

308 22 7.1 

Hence the Bottini operation cannot be regarded as the perfectly 
innocuous procedure some surgeons would have us believe it to 
be. It is slightly more dangerous as an operation, other things 
being equal, than the formation of a suprapubic fistula; but its 
death-rate even in the hands of experienced operators is not less 
than that of perineal, and is inconsiderably less than that of supra- 
pubic prostatectomy. 

Beyond these primary facts, on which there is practical agree- 
ment, the advocates of the Bottini operation deny, or at any rate 
ignore, the force of the many objections raised against this form 
of treatment. The main objections which it appears to me are 
inherent in this operation, as an operation, and quite apart from 
the question of its applicability to every case, are the following: 

(a) The special requirements oj the operation. 

1. The need of special apparatus. With no other form of 



180 Local Treatment. 

treatment is special apparatus required. The various forms of 
drainage tubes and obturators, urinals, etc., used when an arti- 
ficial urethra is established, are not needed for the operation, 
but for the after-treatment ; they are not indispensable, and when 
required are inexpensive. In prostatectomy only the instruments 
employed in general surgery are required. But for the Bottini 
operation not only is the galvano-caustic incisor to be purchased, 
at a cost of fifty dollars or more ; but a battery, or a transformer, 
even more expensive, must be acquired; and a cystoscope for 
preliminary examination is also advisable. These things may 
be very readily obtained and manipulated in a large city hos- 
pital, but are very difficult, sometimes impossible, for the general 
surgeon to procure. 

2. The need of special knowledge of electricity in general, 
and of the mechanism of these instruments in particular. To 
one who has grown up with electric currents in constant use all 
about him, these matters come easily; but electricity is not even 
yet so universally used that every surgeon is familiar with its 
applications. The apparatus is difficult to keep in order even 
when attended to by expert electricians, and as it is prone to 
prove a failure at the eleventh hour, their services are not always 
obtainable. 

3. The need of special skill and dexterity in endourethral and 
intravesical surgery. Every operation, to be sure, requires special 
skill and dexterity of some kind; but an experience and manual 
dexterity sufficient for safe operating in all kinds of abdominal 
surgery will be obtained by the performance of ten or fifteen 
operations for acute appendicitis with its complications, very 
much more easily than will dexterity for the successful perform- 
ance of a Bottini operation be acquired by an even greater num- 
ber of cystotomies or lithotomies. The remarks of Keyes [133], 
quoted above, in reference to litholapaxy, are applicable to this 
point: the surgeon who is fit to perform a Bottini operation with 
surety is he who has had great experience with the cystoscope, 
with Bigelow's apparatus, and with previous Bottini operations. 



The Bottini Operation. 181 

(b) The uncertainties o] the operation. 

i. As to the form and outline of the prostate. This objec- 
tion may be partly overcome by the use of the cystoscope, where 
the state of the bladder and urethra will permit prolonged instru- 
mental examination; but even thus the chance for errors in 
diagnosis is very great: a projection thought to be prostatic may 
turn out to be a fold of the bladder wall, and instead of burn- 
ing grooves in the enlarged organ, the peritoneal cavity will be 
opened, as has happened to very skillful operators. 

2. As to the position of the beak of the instrument. Many 
good and skillful operators have placed the beak of the instru- 
ment as desired, and have ascertained its position by palpation 
with a finger in the rectum; feeling themselves safe, they have 
then turned on the current, and, as just mentioned, the result has 
shown that the beak of the incisor was hooked over a fold of 
the bladder, and not in contact with the prostate at all. 

3. As to the temperature of the blade. It is impossible to 
be sure that a current sufficiently strong to heat the incisor to 
a white heat outside of the bladder will accomplish the same 
result when the blade is within the bladder and in contact with 
the prostate. 

4. As to the length and depth of the incisions. The length 
is roughly gauged by the scale on the shaft of the instrument; 
but if the beak " backs off," or is forced away from the prostate, 
instead of the knife blade sinking into the prostatic substance, 
a very erroneous impression may be obtained. The depth is 
more accurately assured by the use of Young's [260] blades 
of graduated sizes, but even thus absolute surety does not 
exist. 

4. As to the amount of tissue destroyed. This follows directly 
from the uncertainty as to the heat of the blade and as to the 
length and depth of the incisions. 

(c) The accidents of the operation. These it is impossible 
always to prevent, in the midst of so many uncertainties. 



182 Local Treatment. 

i. The apparatus may fail to work, although apparently in 
perfect order. This accident may occur either before the instru- 
ment is introduced, or even if the blade became heated properly 
then, it may fail to do so a minute later, when it has been passed 
into the bladder. Here the operation must be abandoned. 

2. The incisions may be too long, or, 

3. The beak may slip. In either case very serious accidents 
may follow. Freudenberg [81] burned a hole into the rectum. 
Young [260] burned through the membranous urethra, and had 
to do an external urethrotomy to check the haemorrhage. The 
space of Retzius has been entered, causing fatal suppuration 
(Konig [137]); in a patient of Willy Meyer's [165] an anterior 
incision caused death from suppuration in the space of Retzius, 
although at autopsy no perforation could be found; in a patient 
of v. Frisch [91] severe suppuration occurred in this situation 
from perforation, but recovery finally ensued. Fatal peritonitis 
has been produced by direct perforation into the peritoneal 
cavity (Freudenberg [84]). 

4. The blade of the incisor may bend. Bouffieur [31] states 
that this accident occurred to Czerny, who split the urethra from 
one end to the other in withdrawing the damaged instrument. 
According to Burckhardt [212], among others who have experi- 
enced this accident are Freudenberg, Konig, and Rydygier. 

5. The cooling apparatus may fail to work, and the vesical 
neck and the urethra be charred before the less sensitive hands 
of the surgeon perceive the accident by themselves becoming 
blistered. In Freudenberg' s [84] operation the bending of the 
cautery blade above referred to was caused by his momentarily 
loosening his hold on the instrument because it burned his fingers. 

(d) The limitations 0} the operation. 

1. It can be used only where the urethra is freely open to 
instrumentation. Hence in cases complicated by strictures, and 
where the prostatic urethra is much deformed, this operation 
is inapplicable. 



The Bottini Operation. 183 

2. It can be used for a smaller variety of enlarged prostates 
than any other operation. Those which obstruct by their bulk 
cannot be sufficiently reduced in size by it. Pedunculated out- 
growths, even with Young's [260] ingenious incisions, are not 
satisfactorily treated. Prostates which are still increasing in 
size will probably continue to do so after the incisions have 
healed. 

3. It does not admit of the proper treatment of other patho- 
logical conditions at the same sitting. Calculus except in rare 
instances is more satisfactorily and safely removed by lithotomy 
than by litholapaxy; and even were the case to be deemed a 
suitable one for litholapaxy, this operation might be impossible 
until the prostatic obstruction had been overcome. Sometimes 
the very presence of calculus is masked by the enlarged prostate; 
and even after a Bottini operation the prostate might still be too 
large to permit of litholapaxy. 

Drainage of the bladder is very imperfect after a Bottini 
operation, and where it is particularly indicated this form of 
treatment cannot be too highly condemned. 

(e) The dangers in the after-treatment. 

1. Retention of urine. The prostate may swell up so much 
after the operation that not only can no urine be passed, but not 
even can a catheter be introduced to draw off the urine. Willy 
Meyer [164] and Freudenberg [84], among other surgeons, have 
experienced this complication, which necessitates puncture of 
the bladder; or, if the swelling does not soon spontaneously 
subside, a formal cystotomy. In v. Frisch's [91] patient a 
catheter was successfully passed after retention had existed for 
some time. 

2. Secondary haemorrhage. It is impossible to determine 
when this complication is to be anticipated, and hence to guard 
against its occurrence. It may occur spontaneously on the 
separation of the sloughs, or may be caused by the necessary 
passage of a catheter for retention. It has occurred several 



1 84 Local Treatment. 

times when a permanent catheter left in the bladder after the 
operation has been first withdrawn. The haemorrhage may be 
severe, and may even require suprapubic cystotomy with douch- 
ing or packing of the bladder to relieve it. 

3. Sloughs may plug the urethra or catheter. 

4. Sloughs may be retained in the bladder, causing foul 
cystitis, or intense suffering. 

5. The liability to epididymitis, orchitis, and other affections 
usually classed as " accidents " of the operation. Watson's [246] 
statistics show that after the Bottini operation 22 per cent, of 
the patients develope orchitis, recto-urethral fistulae, or incon- 
tinence. The corresponding figures for perineal and suprapubic 
prostatectomy, the latter including also suprapubic fistulae and 
the former perineal fistulae, are 7.2 per cent, for the perineal opera- 
tion, and 6 per cent, for the suprapubic. 

6. The liability to sepsis. Over half of the deaths in Wat- 
son's [246] series were caused by sepsis. 

Besides these objections to the operation itself, there is the 
paramount objection that its results are less satisfactory than 
those obtained by other methods of treatment. 

1. In the first place, the results are uncertain As seen al- 
ready, death may occur from perforation of the bladder when no 
apparent mishap during the course of the operation indicated 
anything wrong. Watson [246] found that nearly one-eighth of 
all deaths was due to this cause. This is the uncertainty as to 
the immediate result; but the uncertainty as to the ultimate 
result is even greater. In 13 per cent, of cases, according to 
Watson's statistics, the operation has to be repeated; while in 
30.4 per cent, only do cures result, and "good results," not cures, 
form only 84.4 per cent, of the whole. 

These figures also appear to be somewhat rose-coloured. Ac- 
cording to recent statistics collected by Burckhardt [212], among 
960 cases, from 73 to 77 per cent, could be classed as having 



The Bottini Operation. 185 

the urinary function restored or improved, and from 14 to 18 per 
cent, were without result. The following table shows Burck- 
hardt's exact figures: 

Restoration or 
Improvement of Without 
Author. Cases. Function. Result. Death. 

Wossidlo no 73-6% 18.2% 8.2% 

v. Frisch 127 75.6% 17.3% 7.1% 

W.Meyer 164 75-6% 15-8% 8.5% 

Stockmann 229 77-7% i4-°% 8.3% 

Freudenberg 255 76.5% 14.9% 8.6% 

E. Burckhardt 75 74-6% 14-6% 10.6% 

2. Besides being uncertain, the results are not permanent. 
Relief may follow for a time, and the patient be classed as, and 
consider himself, cured. This state may last for weeks, or even 
for months; but it is rarely permanent. Sooner or later, in 
the large majority of cases, the symptoms return: some patients 
endure their troubles; others are persuaded into a repetition of 
the Bottini operation; and still others submit to a prostatectomy, 
which is in all probability rendered much more difficult as a 
result of the periprostatitis set up by the previous operation. A 
few die before their urinary troubles again become pronounced. 

We may conclude, then, that the Bottini operation is one 
which only specially trained operators should undertake; which 
even in their hands has a mortality nearly as great as radical 
removal of the prostate; which is of extremely limited applica- 
tion, and is without result in about one-fifth of the cases that 
recover. 

But there are undoubtedly a few points in favour of the 
Bottini operation, and an impartial consideration of these is 
required. 

1. It does not require general anaesthesia. There are some 
patients whose condition is such that, while they require no 
emergency treatment, for which state one of the palliative opera- 
tions already considered would be indicated, yet they are unable 
to endure the shock of a radical operation, entailing as it does 



1 86 Local Treatment. 

general anaesthesia. For such patients the Bottini operation 
seems well adapted, provided, of course, the objections already 
discussed do not apply to the patient in question: for instance, 
provided the cystitis is not so severe as to require drainage of the 
bladder. If a patient such as this failed to recuperate enough, 
after drainage had been instituted, to endure a radical operation, 
he could still be treated and probably improved by a Bottini 
operation, drainage of the bladder by the artificial urethra pre- 
viously formed continuing as long afterwards as required. 

2. Patients will often be willing to have a galvano-caustic 
prostatotomy done, when the idea of any cutting operation would 
make them aghast. 

3. Temporary success by one such operation justifies its 
repetition in a patient unfit for more radical treatment. At 
times a patient is found who experiences less discomfort from 
the performance of a Bottini operation than from the examination 
of the bladder with a stone searcher. Freudenberg [84] says he 
has never had occasion to regret the repeated performance of 
this operation. 

4. The comparatively slight liability to pulmonary complica- 
tions and shock renders it a suitable procedure where these are 
more to be feared than sepsis. 

5. The shorter period of confinement to bed required in 
favourable cases. Many of these patients may be allowed to 
leave their bed permanently on the second or third day. In the 
aged any confinement to bed is harmful, because it upsets long- 
continued habits at a time of life when any deviation from the 
usual routine is apt to be disastrous. 

The class of patients, then, where I would recommend the 
employment of the Bottini operation is extremely limited. It is 
to be advised only as a makeshift, where no other form of treat- 
ment is practicable. I would not employ it in very early cases 
simply because I believe that most of the symptoms can be re- 
lieved by regular catheterization, which is less dangerous. The 



The Bottini Operation. 187 

malady of those patients " radically cured" by the Bottini opera- 
tion performed within the first few weeks or months after the 
developement of symptoms, is not exempt from the suspicion 
of having been not enlargement of the prostate at all, but merely 
congestion; and it is quite within the bounds of reason to sup- 
pose that these same patients would have benefitted from an 
equally radical cure, obtained with much less danger, by means 
of intermittent or continuous catheterization extending over a 
period of a few weeks. 

In slightly more advanced cases, where the enlargement of 
the prostate is undeniable, and catheterization has been pushed 
to its limit, galvano-caustic prostatotomy may be the only form 
of operation to which the patient will consent; and may there- 
fore properly be employed as a pis-aller provided bladder drain- 
age can be procured or is not required. 

In fully developed cases the Bottini operation is useless. 
The more pronounced the adenomatous character of the enlarge- 
ment, the less can the Bottini operation be expected to prevent 
a continuance of the overgrowth, and the more futile is its em- 
ployment. Even in the fibrous form of enlargement, where the 
Bottini operation would have a better chance of success, a peri- 
neal prostatectomy affords a surer probability of cure; and 
in any case where the diseased gland can be safely removed, it 
is mere folly to waste time with an operation which is too dan- 
gerous for mere palliation. Where the reward is higher, greater 
risk may be justifiable; but the reward for the patient of this 
class treated by the Bottini operation is not high enough. 

Among patients very far advanced in the course of prostatism 
there is one class where I am inclined to favour the Bottini opera- 
tion. It is that where the prostate is small and sclerosed, and 
where its removal by prostatectomy even in otherwise healthy 
patients would be extremely difficult. Here I think a Bottini 
operation may be fairly considered the best form of treatment, 
provided further treatment than catheterism or bladder drainage 



1 88 Local Treatment. 

is indicated. It is like the old question of an incurable leg 
ulcer — the only way to cure the patient is by amputating his 
leg; but it is much more to the patient's advantage to have an 
incurable leg ulcer all his life than to risk losing his life by so 
crippling an operation. So with the old prostatic — it is often 
better, much better, to let him eke out the remainder of his days 
with catheterism or a urinary fistula than to risk snuffing out 
his life at once by an operation with even the low mortality 
attendant upon that of Bottini. 

Technique of the Bottini Operation of Galvano-caustic Pro- 
statotomy. — Description of apparatus: The original apparatus of 
Bottini [27] consisted of an Incisor (Incisore prostatico) and a 
Cauterizer (Cauterizzatore prostatico) . With the latter he burned 
the surface of the gland in various places, and with the former 
he charred grooves in its substance. The cauterizer was em- 
ployed chiefly in the treatment of chronic inflammations, and is 
now almost universally abandoned ; so that only the incisor need 
be particularly described. 

The galvano-caustic incisor is a metal instrument of the 
general form of a stone-searcher, but consisting of two blades, 
male and female, like a lithotrite. The instrument is introduced 
closed into the bladder, and the male blade, which is heated by 
a galvanic current conducted along its interior, is made to burn 
grooves by withdrawing it from contact with the female blade. 
The female blade remains fixed at the position in which it is 
first placed, being hooked over the prostate in the desired situa- 
tion; and the male blade, being shorter, burns a groove not so 
deep as the position maintained by the female blade. 

The cutting part of the male blade (the knife) was origin- 
ally made of platinum; but by Freudenberg's modification it 
was made of an alloy of platinum with iridium, which substance 
became more readily heated, since it offered greater resistance 
to the passage of the electric current. In Bottini's instrument 
the current passed to and from the knife blade along two wires, 



PLATE LXXI, 




The Bottini Operation. 189 

the knife being somewhat unsteadily fixed at their extremity. 
On this account the blade often bent when in use, and accordingly 
when an attempt was made to return it to its groove in the female 
blade, failure resulted. Freudenberg [80] attached the knife 
to a single strong wire, which would carry a stronger current 
than the fine wire formerly employed, and allowed of the firmer 
fixation of the knife. The return current passed through the 
shaft of the male blade. Even thus, however, the danger of the 
blade becoming bent is not entirely obviated. 

It was found that not only did the current heat the platinum 
knife to a red or white heat, but that the whole instrument be- 
came so hot as to seriously injure the urethra, and to be very 
difficult to hold. Accordingly in 1882 Bottini added an appli- 
ance by which cold water was constantly passed through the 
interior of the shaft of the instrument, as far down as the plati- 
num knife, so that the shaft was no longer dangerously hot. 
Freudenberg improved this arrangement so that the cooling 
stream flowed also through the handle of the instrument, which 
even in Bottini's modified apparatus became at times uncom- 
fortably hot. He also made the handle more convenient to hold, 
and had the whole instrument so constructed that it is readily 
sterilized by boiling. The rubber tubing by which the cold 
stream is conducted to and collected from the incisor should be 
strong and quite resilient, so that by no possibility can it kink 
and interrupt the flow of water. 

The knife-blade is withdrawn from its groove in the female 
blade by a screw in the handle, resembling an Archimedean 
screw; and a centimetre scale is attached so that the distance 
through which the knife-blade has been drawn may be readily 
seen. 

Contacts for the electric current are also provided, with a 
separate screw to make and break the current. For producing 
the galvanic current a special battery is employed; or a trans- 
former may be connected with the ordinary interrupted current 
of the incandescent light apparatus. 



190 Local Treatment. 

Dr. Hugh H. Young [260], of the Johns Hopkins University, 
has made some valuable modifications of Freudenberg' s appara- 
tus, the chief of which is an increase in the angle at which the 
beak is affixed to the shaft, so that the danger of the beak slip- 
ping while in use is minimized. He has also provided cautery- 
blades of various sizes, so as to suit different degrees of prostatic 
overgrowth: these blades are readily interchangeable. 

Still further modifications of the Freudenberg apparatus 
have appeared. Schlagintweit [206] introduced an instrument in 
which the knife-blade was brought forward by a sliding move- 
ment instead of a screw, being pulled back again to its first posi- 
tion by a spring. By this arrangement, which enables the entire 
mechanism to be controlled by one hand, the surgeon is free to 
retain a finger of the other hand in the rectum throughout the 
operation. Wossidlo [259], and subsequently other surgeons, have 
invented contrivances by which a cystoscope is combined in one 
instrument with the galvano-caustic incisor (Incisionskystoskop), 
by which it is expected that the surgeon can see every manipu- 
lation during the course of the operation. A separate current and 
set of wires is, of course, required for the cystoscopic mechanism. 

Such modifications as the above, however, appear to me 
more ingenious than practically useful. 

The Bottini operation was first performed with an empty 
bladder ; but it was found impossible to thus avoid burning other 
parts of the vesical wall, so that this plan was abandoned. The 
bladder was distended with liquid; here the operator was be- 
tween the horns of a dilemma: either the knife did not become 
hot enough to burn, or all the water became so hot as to be un- 
endurable. Finally, at the present day, the operation is usually 
done after distending the bladder with air. For the disadvan- 
tages of this method, see page 1 70.* 

* Rosens tein [201 a] has recently called attention to another element of danger in 
the Bottini operation. He records the case of a man on whom Freudenberg operated 
by galvanocaustic prostatotomy, the bladder being distended with 200 ccm. of air. As 



PLATE LXXJ 





i. Young's incisor, 2. Freudenberg's incisor for the Bottini apparatus. 



The Bottini Operation. 191 

The operation: The patient should have his genitals shaved 
and cleansed, as in various emergencies a cutting operation may 
become necessary. 

One and a half to two drachms of a one per cent, solution 
of cocaine (five per cent., if eucaine) should then be instilled 
into the posterior urethra. A cystoscopic examination is very 
desirable, but should, if possible, have been conducted on a 
previous occasion. It is valuable both from the visual informa- 
tion obtained, and because it will serve to show the degree of 
tolerance to urethral instrumentation. Where this is not well 
borne, the Bottini operation is not advisable. 

In about five minutes' time sufficient local anaesthesia will 
have been obtained. The bladder should then be distended 
with a moderate amount of air, which is readily introduced 
through a rubber catheter by means of a hand syringe. The ut- 
most gentleness should be used during the injection, and the 
bladder should not be fully distended. The patient's feelings are 
a safe guide. It is rarely requisite to inject so much air as to 
render the hypogastric note tympanitic ; for it is to be recollected 
that the bladder is often small and contracted, and will bear 
very little distention. Previous experience as to its capacity for 
fluids is a help. It is of no use to employ sterilized air, as the 
microorganisms in the normal air may be safely disregarded. 
The danger of producing emphysema should be borne in mind. 

Meanwhile, the instrument should be tested. The current 
is to be turned on, and the time and the strength of current re- 
quired for the desired heat to be obtained carefully noted. It is 
usually thought best to operate with the blade at a white heat, 
but a bright red will suffice in the majority of cases, and is less 
likely to cause haemorrhage. The blade is then to be tried, by 

the third incision was being made, an explosion like the bursting of a balloon was heard; 
laparotomy disclosed a ruptured bladder, which subsequent experimentation showed 
to be due to the " Leidenfrost " phenomenon — the condensation of steam on the hot in- 
cisor. The patient died from pneumonia on the eleventh day. 



19 2 Local Treatment. 

burning a piece of moist sterile gauze, to determine whether 
the heat will be maintained when the knife begins to incise the 
prostate. The cooling apparatus must also be tested. 

This examination having been satisfactorily concluded, the 
blade should be allowed to cool before being introduced into 
the bladder. 

When the instrument has been introduced, the surgeon must 
place the beak, inverted, over the prostatic obstruction, in the 
position previously decided upon; and should ascertain the 
correctness of its position by palpation with a finger in the rec- 
tum. If there seems to be any danger of the beak of the instru- 
ment slipping from its position during the operation, an assistant 
should keep his finger in the rectum throughout the pro- 
cedures; or, which I prefer, the operator himself should keep 
his finger in contact with the beak of the instrument, through 
the medium of the rectum, and hold the shaft of the instrument 
with the other hand, entrusting to a skillful assistant the task 
of manipulating the screw to incise the prostate. The most 
delicate part of the whole operation consists in holding the 
female blade in the same unchanging position during the whole 
time that the male blade is incandescent. This task the oper- 
ator should always assume himself. 

Matters being thus arranged, the cooling current is to be 
turned on, and one assistant should give his entire attention 
to this feature of the operation, seeing that the return flow from 
the cooling tube never for a moment is interrupted. 

Then the current contact should be made, and the time re- 
quired to heat the knife be allowed to elapse before the incisions 
are proceeded with. It usually requires about fifteen seconds 
to bring the knife to a white heat; but it is well to allow a 
little longer time to pass than that found requisite outside of the 
bladder. 

When the knife blade is believed to have acquired the requi- 
site heat, the screw is to be turned so as to advance the male 



PLATE LXXIII. 




The Bottini Incision in Use. 

Below is shown a transverse section of the prostatic urethra after its floor has been divided 

by the galvano-cautery.- — {After Socin and Burckhardt.) 



The Bottini Operation. 193 

blade, from its position within the groove of the female blade, 
forward into the gland. The length of the incision will vary 
in different cases; it should rarely be more than two-thirds of 
the diameter of the prostate, and should never exceed three- 
quarters of this distance. Previous repeated instrumental and 
cystoscopic examinations will, as a rule, have given information 
as to the size of the gland sufficiently accurate for practical pur- 
poses. It is thus seen that the incision need rarely exceed three 
and a half or four centimetres in length. The depth can be 
regulated by making choice of a suitably sized blade from among 
those accompanying Young's apparatus. The rate at which the 
incision is to be made will vary slightly with the heat of the 
knife and the density of the gland; but, as a rule, a rate of one 
centimetre a minute is quite rapid enough. If an attempt is 
made to force the blade through the prostate at a quicker rate, 
it will often be found that the beak "backs off," instead of the 
blade advancing; or at least that annoying haemorrhage occurs 
because the prostate is torn rather than seared. 

When an incision of the desired length has been made, the 
knife-blade must be returned to its first position in contact with 
the female blade, and as this is done the current should be in- 
creased, so as to thoroughly consume any particles of prostatic 
tissue still clinging to the knife. When the male blade has 
again reached its place in contact with the female blade, the 
electric current is to be shut off. 

Before making another incision the blade should be allowed 
to cool. The cooling current should continue in action between 
the making of the incisions, as well as during their formation. 
Some surgeons recommend removing the instrument from the 
bladder after the completion of each incision, so as to make sure 
that no particles of charred tissue adhere to the knife-blade; 
but I think that if the incisions are made deliberately and with- 
out force, and if the current is increased during the return of 
the knife-blade, this accident is not liable to occur; besides 
14 p 



194 Local Treatment. 

which, the removal and reinsertion of the instrument produces 
unnecessary traumatism of the charred tissues. 

I do not think that more than three incisions should be made. 
At times, one or two will be enough. An incision should never 
be made anteriorly, above the urethra, on account of the danger, 
already discussed, of burning into the space of Retzius. Usually 
one incision is made in the median line, so as to lower the vesical 
orifice of the urethra; if one lobe be more enlarged than the 
other, a second incision will be made into it, in a slightly radiat- 
ing manner; and if both lateral lobes are much enlarged, an 
incision may be made on each side, in one of the forms indicated 
in the accompanying diagrams. (Plate lxxiv.) If the bar across 
the neck of the bladder be very thick and broad, two or three 
nearly parallel incisions should be made in it. 

A pedunculated mass is not readily treated by the Bottini 
operation. If any attempt is made to cauterize it, either a 
failure results, or its pedicle is severed, and the prostatic tumor 
remains as a foreign body in the bladder. Yet Young [260] has 
managed, in a few cases, to burn through only the anterior part 
of the pedicle, by an oblique incision on each side, thus allowing 
the mass to fall backwards and gradually atrophy as a result 
of the interference with its blood supply. 

At the conclusion of the operation, which does not last more 
than ten or fifteen minutes, the air should be allowed to escape 
from the bladder as far as it spontaneously will; the rest will 
be rapidly absorbed. Some surgeons, notably Burckhardt [212], 
have insisted on the propriety of leaving a permanent catheter 
in the bladder at the conclusion of the operation, on account of 
the fear they entertain of retention of urine setting in from 
oedema of the prostate and deep urethra. But I do not think 
such a procedure is advisable. In cases where this operation 
is to be employed, there should be no question of the bladder 
being able to take care of itself. If the tissues resent instru- 
mentation, the operation should not be employed; or at least 



PLATE LXXIV. 



B 



l\\ 



\\ 



D 



Various Prostatic Incisions Used in the Bottini Operation. 
A. To divide a simple bar. B. For general enlargement. C. Showing an anterior 
incision which should not be employed. D. For a very thick bar at the neck of the blad- 
der. E. For a prostate with enlargement mainly of the left lobe. 



The Bottini Operation. 195 

bladder drainage should have been previously provided for by 
the formation of an artificial urethra. Moreover, when a per- 
manent catheter is retained, there is considerable danger of the 
sloughs clinging firmly to it, and of their being torn loose when 
it is removed, causing severe secondary haemorrhage. 

Nor am I in favour of the passing of sounds after a Bottini 
operation, at least until three weeks after the operation. 

Secondary haemorrhage, which, apart from sepsis, is the chief 
danger during convalescence, occurs most often during the second 
week; though some bleeding may be present from the time of 
operation; and in one case, narrated by Burckhardt [212], haemor- 
rhage did not appear until the sixteenth day, the first two weeks 
following the operation having been free from untoward symp- 
toms. Catheterization, and every kind of urethral instrumenta- 
tion, should accordingly be avoided, when possible, for at least 
three weeks. If retention of urine once occurs, it will be safer to 
leave the catheter passed in situ, and not to run the risk of 
having to frequently reintroduce it. 

When haemorrhage persists from the time of the operation, 
the retention of a soft-rubber or Mercier catheter, and irrigating 
the bladder with hot solutions, should be employed. At this 
stage of the convalescence it is rarely severe; but if at a later 
period is should be excessive, and if these measures should fail 
to check it, suprapubic cystotomy is indicated, with packing of 
the bleeding area. Or if it can be ascertained that the bleeding 
is urethral, external urethrotomy, with packing around a peri- 
neal tube, should be employed. But, as a rule, the suprapubic 
route will enable the surgeon to have better command of the 
situation. 

3. Castration, etc. — Castration and the various operations 
on the structures of the spermatic cord, first brought prominently 
before the profession over ten years ago, were for a time widely 
employed in the treatment of prostatic enlargement. Castration 
was not only widely employed, but it was indiscriminately em- 



196 Local Treatment. 

ployed, and as a result the mortality rate was so high that the 
operation fell into great disrepute. According to one of its most 
enthusiastic supporters, J. William White [248], the mortality 
for this operation, when employed without due selection of cases, 
was at least eighteen per cent. Cabot [40] placed it at over 
twenty per cent. Other authors have published series of cases, 
gathered from various sources, in which the death-rate ranged 
from 11. 5 per cent, up to nearly 20 per cent. Moullin's [176] per- 
sonal operations, nineteen in number, included two deaths, a 
mortality of 10.55 P er cent.; and Derjuschinsky [63], among 
fifteen cases had four deaths, a mortality of 26.6 per cent. These 
figures do not seem to justify Dr. White's expectation that the 
mortality from the operation would soon fall below seven per 
cent. He managed to reduce the mortality nearly to this point 
by elimination of cases which he considered unsuitable in the 
statistics presented by him before the American Surgical Associa- 
tion in 1895, but Dr. Cabot [40], the next year, pointed out that 
Dr. White's method of deducing results made the comparison 
with other methods of treatment rather unfair. Dr. A. C. Wood 
[257], five years later, in 1900, found that even in selected cases 
the mortality did not fall below eight per cent., unless it was 
" improved" by similar corrections. 

As regards the restoration or improvement of function fol- 
lowing the operation, the discrepancy among reported cases is 
even greater. According to Burckhardt's [212] tables, the cases 
collected by Englisch showed restoration of function in only 
32.5 per cent, of the whole number; while of those collected 
by Cabot, 83.6 per cent, were reported as having had their urin- 
ary function restored. In regard to mere improvement of func- 
tion, Cabot's figures gave 6.6 per cent., and Englisch's 47.5 per 
cent.; while no result was observable in 20.4 per cent, of the 
cases collected by Burckhardt himself, although in only 4.1 per 
cent, of Englisch's cases was the operation apparently of no 
effect. This wide variation in the statistics shows how very 



PLATE LXXV. 




Showing Eottini Incisions from within the Bladder. — (After Socin and Burck- 

hardt.) 



Castration. 197 

differently different writers will interpret results; and seems 
to render such figures perfectly useless. 

One of the chief dangers after castration is the develope- 
ment of mania, which seems dependent on the removal of the 
sexual organs, and not upon the mere fact of there having been 
an operation of some kind performed, as has been claimed by 
a few writers. It is pretty generally agreed that this compli- 
cation is liable to occur in about one-tenth of the cases. 

Unilateral orchidectomy is even less sure in its ultimate 
effect on the prostate than is the complete operation; for al- 
though the corresponding half of the enlarged organ has in a 
few instances shown very remarkable diminution in size, yet 
in the majority of cases no such change has been observed. 

Vasectomy may be said to be slower, and but little more un- 
certain, in producing results than is double castration, while the 
mortality is somewhat less. Moullin [176] is of the opinion that 
the effect of this operation, as well as that of all others prac- 
tised on the constituents of the spermatic cord, is due to reflex 
action on the nervous system, and thinks such measures more 
likely to be successful if the surrounding structures, containing 
the nerves of the cord and testicle, are considerably injured 
during the manipulations. 

The sudden change from complete retention to voluntary 
urination at times experienced within a few hours after the 
operation cannot be attributed to actual atrophy of the pros- 
tate, but is almost certainly due to the diminution of conges- 
tion. It is extremely improbable that actual atrophy can set 
in until several months have elapsed. 

It is in the glandular forms of enlargement that castration 
is more certain of effecting the desired result, and those who 
are still in favour of its employment are of the opinion that 
it should be limited to patients with fairly soft organs. One 
of the theoretical reasons originally urged for its adoption was 
the supposed similarity of the " prostatic tumors" to the fibro- 



i9 8 Local Treatment. 

myomata occurring in the uterus; and as oophorectomy for such 
affections was then popular, castration was looked upon by some 
as a not unreasonable remedy. And although we now know 
that the prostate is not the homologue of the uterus, and that 
the glandular overgrowth met with in the prostate is not similar 
in pathogenesis to the tumors growing in the uterus, yet the 
fact remains that in some instances double orchidectomy has 
caused marked diminution in bulk of the prostate, and great 
amelioration of the symptoms. 

All these various sexual operations, however, have fallen into 
deserved disuse during the last few years, palliative treatment 
being more successfully applied by means of the Bottini opera- 
tion, which was practically unknown in the nineties; while the 
different methods of prostatectomy have been almost universally 
adopted for radical treatment. 

To my own mind, there is very little ground to dispute the 
theory that castration is surest in its effects on the normal pros- 
tate, and that the more diseased a prostate is, the less reason 
is there for it to be treated by castration. The case reported 
by Moses [172], and before referred to, where a patient developed 
enlargement of the prostate sixteen years after both testicles had 
been removed, is probably not the only one of its kind that has 
occurred. Tobin's [229] point of view is hard to understand: 
he advises castration where the sexual powers, or at any rate 
the desires, still persist; but recommends leaving the testicles 
alone and removing the diseased organ if no such desires are 
present; an opinion, I repeat, which is difficult to understand, 
unless we assume the above dictum to be correct, that castra- 
tion is surest to affect prostates which most nearly approach 
the normal in condition. Some of the observations noted in the 
section on comparative anatomy may also be thought to sup- 
port this view. For instance, the dog is of all animals the most 
prone to prostatic enlargement. It is also the only animal where 
castration at times fails to effect reduction in the size of the pros- 



Castration. 199 

tate. These facts would certainly incline one to the belief that 
castration was more effective on the normal gland than on one 
the seat of pathological enlargement. 

The paragraphs in Chapter V, dealing with the relation of the 
testicle to enlargement of the prostate, may be consulted in con- 
nection with this subject. 

A number of years ago I myself adopted this form of treat- 
ment in several instances, with varying, but generally unsatis- 
factory results; but I do not think it too much to say that I shall 
never employ it again. I regard it as an operation absolutely 
indefensible at the present time. 

For patients who are not able to endure the radical removal 
of their diseased organ, I consider one of the palliative opera- 
tions already considered as the proper method of treatment; 
while for others either a suprapubic or a perineal prostatectomy 
offers the surest and safest cure. 



CHAPTER XI. 

INDICATIONS FOR RADICAL TREATMENT BY SUPRAPUBIC 
AND BY PERINEAL PROSTATECTOMY. 

When palliative treatment fails, then a radical operation is 
indicated. We have before us a choice of two routes of access 
to the prostate gland, the suprapubic and the perineal; and a 
number of variations in the operative procedure by either route. 
To determine which of these many different methods is appli- 
cable to any given case, is the task at present before us. The 
technique of the operations will be described in the next chapter. 

Those surgeons who would confine our operative technique 
to either the suprapubic or the perineal route alone, and who 
do not admit that in some cases one route may justly be pre- 
ferred to the other, so that each is occasionally employed, appear 
to me to be very narrow-minded, and to be looking at the sub- 
ject with prejudiced eyes. There is no more reason to my mind 
for one method of operating on the prostate being exclusively 
applicable to every case, than there is for one incision or one 
avenue of approach being always the only one possible in other 
conditions. For cleaning out the sphenoid cells it will some- 
times be better to approach them from above, through the frontal 
sinuses, while at other times entrance will be more safely gained 
through the middle meatus of the nose. For draining the lesser 
peritoneal cavity it will at times be more advantageous to open 
through the left loin, while at other times the transabdominal 
route will be proper. For the operation of hysterectomy an ab- 
dominal operation will usually be preferred; but there are times 
when a vaginal excision will give better results. So with the 
operation of prostatectomy — the suprapubic operation is in cer- 
tain cases (I think in the majority) in every way preferable to 
that through the perineum. No doubt a skillful surgeon will 



Choice of Operation. 201 

in time become physically able to remove all, or nearly all, en- 
larged prostates by one or the other route exclusively; but this 
does not prove that in a certain few cases a resort to the neglected 
route would not result in an easier operation, and in a surer 
recovery as well. Mr. Freyer, who is inclined to the opinion 
that all enlarged prostates are best removed by means of the 
suprapubic operation which bears his name, nevertheless met 
with one case (Brit. Med. Journ., 1902, ii, 248; ibid., 1903, i, 
901) in which he was unable to remove the prostate by this route; 
and the patient died a couple of days after the unsuccessful opera- 
tion, of heart failure, the bladder being found at autopsy to be 
full of clots. Now, this result is very far from proving that the 
prostate in this individual patient could have been satisfactorily 
removed by a perineal operation, but it certainly shows that no 
one method can be exclusively employed, if we aim to secure 
the best results. And since Mr. Freyer may be supposed to 
possess more skill in the performance of his operation, as he 
certainly has had more experience than any one else, it is but 
reasonable to conclude that where he has failed, others will fail 
as well. I once saw a distinguished surgeon in a neighbouring 
city operate by perineal prostatectomy, and although he finally 
did succeed in extracting the diseased organ, yet he sweat blood 
throughout the operation, and there was for some time grave 
anxiety as to the life of the patient. This surgeon is one of 
those who advocate the perineal operation for every case; and, 
as in the parallel case of Mr. Freyer, it may reasonably be sup- 
posed that those surgeons who employ one operation exclusively 
will be more apt to make it succeed in difficult cases than will 
those who have no objection to resorting to a different method 
when they think the one they usually prefer will fail. There 
may be, indeed I have little doubt that there are, prostates which 
can be removed neither by one route nor the other; but there 
can, I think, be no question that that surgeon will do best for his 
patients, as well as for his own reputation, who is competent to 



202 Radical Treatment. 

resort to either method of treatment, as may seem indicated to 
him. I am glad to see my friend Dr. Senn [209] frankly admit- 
ting that he has encountered some prostates which could not be 
" shelled out," but which were only to be removed by morcellement. 

Speaking in favour of suprapubic prostatectomy, and refer- 
ring to Watson's [243] statement that the perineal distance was 
so great in one-third of the cases as to prevent the completion 
of the operation by the perineal route, McGill [152] said "it is 
unwise to commence an operation with the probability of fail- 
ing in one-third of the cases"; and "it is not advisable to limit 
the ability to perform an operation to gentlemen with preternatur- 
ally long fingers"; while Dr. J. E. Moore [168], of Minneapolis, 
asserts that the operator's fingers grow longer as he grows in 
experience in the perineal operation. Both these surgeons' state- 
ments, while epigrammatic, are no doubt true; but they do not 
invalidate the principle, already laid down, that the ability to 
operate by both routes is a prerequisite for the most successful 
treatment. 

This being accepted as an axiom, it will be the surgeon's 
next duty to determine which cases are suited to each method 
of operation. It will be recollected that enlargement of the pros- 
tate occurs in two main varieties — one variety, the glandular 
or adenomatous overgrowth, constituting the majority of cases; 
while the fibrous enlargement constitutes the minority, and even 
at times approaches more nearly in type to prostatic atrophy, 
or to sclerosis of the neck of the bladder, or is at least conspicuous 
by the relatively slight enlargement compared to the magnitude 
of the symptoms produced. In the former variety, as has already 
been pointed out, the prostate attains a greater size, and at the 
same time the bladder is more often dilated than contracted. 
In the latter variety, which seems rather intimately connected 
with inflammatory changes, the bladder is usually small and 
thickened. Hence at the onset we have the general law laid 
down that the hard, small fibrous prostate will usually be very 



Choice of Operation. 203 

difficult of access by the suprapubic route, while the adenomatous 
organ will at times be so bulky as to absolutely prevent its re- 
moval through the perineum, except by fragmentation. It was 
in a case of the former variety that Mr. Freyer [86] found him- 
self unable to complete his suprapubic operation, for although 
the gland could be satisfactorily reached, yet it could not be 
removed because of its intimate adherence to the surrounding 
structures. As has been frequently insisted upon by Mr. Freyer, 
the adenomatous glands gradually " shake themselves loose" 
from the surrounding structures, tend to resume their bi-lobed 
condition, and are easily enucleated by the finger. But where 
the organ is fibrous, and where periprostatitis (which usually 
has accompanied the developement of this variety) has existed, 
the adhesions between the prostatic capsule and its sheath are 
very dense, no natural line of cleavage exists, and enucleation is 
therefore difficult or impossible. Where prostates which ap- 
proach the fibrous type (for a number are intermediate in char- 
acter) are removed by enucleation, portions of the sheath, or even 
of the levator ani muscle, are frequently found adhering to the 
outer surface of the organ, it having been impossible to separate 
the capsule from the sheath on all sides. Yet in the fibrous 
prostates no subsequent increase in size is to be apprehended, 
and the removal of the floor of the urethra, together with as 
much of the lateral lobes as may be requisite, will result in suffi- 
cient lowering of the vesical outlet to accomplish the desired 
result; whereas a similar operation — a partial prostatectomy — 
in the case of an adenomatous prostate still increasing in size, 
would indeed give temporary relief, but might, on the other 
hand, be followed by continued growth in the remaining portions 
of the prostate, which would eventually cause renewed urinary 
obstruction. For such cases, therefore, complete enucleation is 
preferable, and that this may be more readily and satisfactorily 
accomplished by the suprapubic route I will presently endeavour 
to show. 



204 Radical Treatment. 

But I think that this is the proper place to sound a note of 
conservatism. Many surgeons are rolling up long lists of suc- 
cessful (or unsuccessful) operations by either the suprapubic 
or the perineal route. But it appears to me that some such 
operators may be a little hasty in resorting to operative inter- 
ference; and while one death from neglect to operate at the 
proper time is more reproach to a surgeon than several deaths 
which a timely operation merely failed to prevent, even though 
the former death never appears in his statistics; yet one death 
clearly caused or hastened by an ill-judged resort to operative 
treatment will demand an immense number of successes to blot 
out its remembrance. And I cannot but think that some sur- 
geons are displaying more enthusiasm in adding ten or twenty 
operations every year to their tale of cases, than they are in seek- 
ing the best interests of their patients. 

And in connection with these thoughts, I would like to in- 
sist upon the propriety of not doing too much at any one opera- 
tion. If we open the bladder to drain it for cystitis, let us be 
satisfied, except in rare instances, if we secure the desired drain- 
age, and let us not attempt to remove the prostate at the same 
time. If we open the bladder prepared to do a prostatectomy, 
and find a pedunculated outgrowth acting as a ball- valve against 
the vesical orifice of the urethra, let us be satisfied to remove 
it, and leave the remainder of the prostate alone. I do not 
think I can justly be accused of being a timid operator, but I 
am free to confess that I am afraid to do too much to some of 
these decrepit old men: their tenure on life is slight, and press- 
ing our manipulations too far may at any moment loose the silver 
cord, and instead of curing our patient by a brilliant operation, 
we shall have killed him by meddlesome surgery. 

I know quite well that in a certain number of cases removal 
of a pedunculated outgrowth has not prevented a return of symp- 
toms ; but, on the other hand, I am perfectly familiar with several 
instances where the most radical, dangerous, brilliant, and re- 



Choice of Operation. 205 

markable operation in the world could have had no more suc- 
cessful result than the simple snipping off of such a ball-valve, 
with scarcely more present danger to the patient than that of 
the anaesthetic. And inasmuch as Mr. Freyer, for whose auth- 
ority and opinion I have nevertheless the utmost respect, has 
recently made somewhat caustic remarks upon the futility of 
employing anything else than total enucleation in any such cases, 
I take pleasure in here recording the case of a patient of my 
own (only one out of several) who was cured by this proce- 
dure. 

J. S., aged sixty-nine years, had been forced, for seven or eight 
years, to rise during the night to urinate. The desire was im- 
perative, and sometimes recurred ten or twelve times during the 
same night. There was difficulty in starting the stream, and only 
a small quantity was passed at any one time. Vesical tenesmus 
occurred at frequent intervals, both day and night. On ad- 
mission to the German Hospital, October 7, 1902, the patient was 
found to be plethoric; his colour was sallow; his arteries were 
somewhat atheromatous, and their tension increased. His 
heart-sounds were muffled, and the second cardiac sound was 
accentuated throughout. His lungs were emphysematous. There 
was tenderness in the pubic region, and combined intravesical 
and rectal examination demonstrated an enlarged " median 
lobe" of the prostate. There were 60 cc. of residual urine. On 
October 8, 1902, the pedunculated "median lobe" was removed 
by suprapubic cystotomy, by means of large forceps. Bleeding 
was free, but easily controlled. A rubber tube was inserted 
through the suprapubic wound, which was not sutured. The 
patient was discharged, well, in two weeks. I have heard from 
him frequently since, and on recent inquiry ascertained that his 
urination was normal in every respect. 

Other similar cases are to be found in prostatic literature, 
but they seem to have passed from the memory of many in the 
profession. Burckhardt [212, p. 224] records the case of a patient 



2o6 Radical Treatment. 

who had suffered from urinary symptoms for five and a half 
years; and who for one year had had frequent attacks of re- 
tention of urine. By the removal of a projecting " middle lobe" 
by suprapubic cystotomy, all the symptoms were relieved; and 
when last seen, four and a half years after the operation, the 
patient was in good health, and his urinary functions were nor- 
mally performed. Prof. Ashhurst [8] reported a case of similar 
nature, as long ago as 1882. The patient for five years had 
been absolutely dependent on the catheter. Finally the end 
of his catheter broke off and remained in the bladder. After 
suffering for seven weeks from this added discomfort, he applied 
for treatment. The foreign body was removed by median peri- 
neal cystotomy, and a pedunculated "median lobe" of the pros- 
tate was removed at the same time. On recovery the patient 
found to his great delight that he could pass his urine in the 
normal manner, and had no further use for the catheter. Har- 
rison [117] has recently reported another such recovery. 

To these few instances others might be added, but those 
given are sufficient to emphasize my point. 

The preferable route for total enucleation of the prostate is 
the suprapubic. The prostate lies upon the triangular liga- 
ment, and above the aponeurosis of Denonvilliers; neither of 
these structures, so important in completing the floor of the 
pelvis, is divided when the prostate is lifted off them, and de- 
livered into the cavity of the bladder. And when the prostate 
is adenomatous in character its enucleation is accomplished with 
surprising ease. Whether the prostatic urethra is removed or 
not makes apparently no difference in the functional result. In 
many of the modern perineal operations it is sacrificed in a similar 
manner. Indeed, Dr. Goodfellow's [98] procedure appears to 
be precisely the same as Mr. Freyer's, except that the former 
removes the prostate through a perineal incision, and is less able 
to see what he is doing during the operation. 

The approach to the prostate by the suprapubic route is 



Choice of Operation. 207 

through structures which are less vascular, and less liable to 
permanent injury from the necessary manipulations. They are, 
moreover, not required for the function of urination. It is cus- 
tomary to cast in the teeth of the suprapubic operator the fact 
that he makes two incisions in the bladder wall, one on its supe- 
rior surface, to enter its cavity, and another in its floor to reach 
the prostate ; and it is pointed out by perineal operators that the 
organ whose removal we are attempting lies entirely outside the 
bladder, and that by the perineal approach the bladder wall is 
not divided. But those surgeons who, like Goodfellow, insist 
upon the propriety of entering the enucleating finger into the 
bladder cavity before beginning the enucleation, surely divide 
the floor of this viscus during their manoeuvres; while those 
who, like Proust [196] and Young [261], approach the prostate 
from its lower side, employ an extensive dissection separating 
the rectum from the anterior structures, and dividing the base of, 
or working around the lower margin of the triangular ligament, 
and thus in either case form a wound which, as their results show, 
is more apt to result in a permanent fistula, while it affords no 
better drainage than is procured by the suprapubic operation. 
As has been pointed out by McGill [152] and W. G. Richardson 
[199], drainage is really better by the suprapubic wound; for it is 
a fact that where the bladder is drained both ways simultaneously 
almost all the urine escapes by the suprapubic tube, and that when 
both tubes are removed, the perineal tract closes first. This is, 
of course, where the perineal wound is a simple median ure- 
throtomy, since, as has already been said, the wound left after 
a suprapubic cystotomy closes more rapidly than that resulting 
from the extensive perineal operations which are now in fashion. 
As to the objection that the prostate is an extravesical organ, 
it may be replied that it is so to the same extent as, but scarcely 
more so than the appendix is an extraperitoneal structure; for 
the enlarged prostate (and it is only that form that we are dis- 
cussing now) almost invariably becomes chiefly intravesical in 



208 



Radical Treatment. 



character, and it is therefore no more unsurgical to traverse the 
bladder to reach it than it is to attack the appendix by a trans- 
peritoneal route; and yet we all know that an inflamed appen- 
dix may readily, if circumstances require it, be stripped out 
from its peritoneal covering, leaving this in place like the empty 
finger of a glove, much as the perineal operators advocate scoop- 
ing out submucous prostatic outgrowths from beneath the floor 
of the bladder without opening this organ; but nevertheless no 
one will prefer an extraperitoneal approach to the appendix. 
The enlarged prostate, in fact, is covered only by mucous mem- 
brane, or at most by attenuated muscular tissue which is as 
much prostatic capsule as it is bladder wall. 

The mortality of Freyer's operation is higher than that shown 
by the statistics of the modern perineal operations; but of the 
cases that recover, those that are classed as good results form 
a somewhat larger, and those with perfect cures a considerably 
larger proportion. 

FREYER'S OPERATION. 

Mortality 
Operator. Cases. Deaths. Per Cent. 

Barling [13] 10 3 30.00 

Deaver [58] 23 3 13.04 

Freyer [90] no 10 9.09 

Horwitz [126] n 2 18.18 

Loumeau [146] 1 o 0.0 

McRae [157] 3 o 0.0 

Moynihan [178] 12 1 8.33 

Stoker [217J 3 o 0.0 

Wanless [241] 6 1 16.66 

Wiener [250] 7 o 0.0 

186 20 Jo. 75 



PERINEAL PROSTATECTOMY. 

Mortality 

Operator. Cases. Deaths. Per Cent. 

Albarran [2] 35 1 2.85 

Deaver [57] 5 2 40.0 

Ferguson [77] 6 o 0.0 

Goodfellow [98] 73 2 2.74 

Horwitz [126] 38 2 5.26 



Choice of Operation. 209 

PERINEAL PROSTATECTOMY.— {Continued.) 

Mortality 
Operator. Cases. Deaths. Per Cent. 

MacGowan [154] 28 4 14.28 

Morton [171 a] 10 2 20.0 

Murphy [182] 48 5 10.41 

Syms[22i] 26 2 7.69 

Verhoogen [233] 3 o 0.0 

Young [262] 50 2 4.0 

322 22 6.83 

I think I may be allowed, without false pride or modesty, 
to call attention to the character of my two fatal cases of peri- 
neal prostatectomy. The first patient was seventy-one years of 
age, but in almost desperate physical condition, being in the 
advanced stages of paralysis agitans. He had had urinary 
troubles for twenty years, extending back nearly to an attack 
of gonorrhoea at the age of forty-six. For the past six years he 
had employed a catheter, first every five hours, latterly every 
half hour. Recognizing that he was unsuited for an operation, 
I kept him in the hospital, and endeavoured to build up his 
system by diet, tonics, etc.; I also established permanent drain- 
age by an inlying catheter, which he bore fairly well. After 
nearly two months, I operated, removing the prostate through 
the perineum by morcellement. The patient died in fifty-four 
hours, there having been no unfavourable local occurrences, 
such as bleeding. 

My second fatal case was sixty years of age. He had had 
urinary troubles for ten years, rising two or three times at night. 
In August, 1901, his condition grew worse, and he had to pass 
his urine hourly, day and night. The residual urine was from 
30 to 50 cc. The prostate was large, hard, tender, irregular, 
and the size of a small orange. He passed from 1500 to 2000 
cc. of urine daily. On October 3d I did a Bottini operation. 
This gave him relief for five weeks. Beginning in February, 
1902, he passed urine every fifteen minutes. To relieve this 
I established suprapubic drainage on March 3d. To my great 
15 p 



210 Radical Treatment. 

regret this gave relief for only two days, when uncontrollable 
tenesmus recurred, and he prayed for any operation for relief. 
After waiting in vain for some improvement, but not wanting to 
wait too long, in such circumstances, on March 18th I did peri- 
neal prostatectomy. The patient died in twenty-four hours 
from shock and suppression of urine. 

Watson [246] collected from various sources 243 cases of total 
suprapubic prostatectomy, with 28 deaths, a mortality of 11. 5 
per cent.; while among 530 total perineal operations he found 
33 deaths, a mortality of 6.2 per cent. His tables showing the 
comparative dangers and successes of these operations, as well 
as those of the Bottini operation, are of much interest. 

TABLE I.— RESULTS. 

Operation. Cured. Good Results. 

Bottini 30.4 % 84.4 % 

Perineal 60.0 % 88.0 % 

Suprapubic 66.0 % 90.0 % 

TABLE II.— CAUSES OF DEATH. 

Pulmonary 
Operation. Uremia Sepsis. Shock. Complications. 

Bottini 27.0% 52.0% 5.0% 8.0% 

Perineal 35.0 % 17.8% 21.4% 17-8 % 

Suprapubic 34.0 % 8.6% 30.0 % 22.0% 

TABLE III.— ACCIDENTS OF OPERATION, INCLUDING ORCHITIS, IN- 
CONTINENCE, PERMANENT FISTULA, ETC. 

Bottini 22.0 % 

Perineal 7.2 % 

Suprapubic 6.0 % 

It is interesting to note that for years the mortality of supra- 
pubic prostatectomy (McGill) when combined with lithotomy 
has been less than when no calculus was present. Burckhardt 
[212] gives 13.8 per cent, mortality (4 deaths in 29 cases) for the 
former operation, and 20.8 per cent. (16 deaths in 77 cases) for 
the latter. This difference can only be explained on the assump- 
tion that the presence of the stone necessitated operative inter- 
ference earlier, and while the patients were more able to endure 



Choice of Operation. 211 

an operation, than when no calculus existed; for as far as the 
other circumstances (cystitis, etc.) are concerned, the patient with 
calculus is in a worse condition for operation than one without. 

The death-rate from Mc Gill's operation (partial suprapubic 
prostatectomy) has always been higher, and will always, it seems, 
remain higher than that of the operation advocated by Mr. Freyer. 
I say it will remain higher, because, however much critics may 
carp, it is not the same operation as Freyer's, and no matter 
how much its technique is improved, the suprapubic enucleation 
of prostatic tumors from the substance of the gland will always 
remain a bloody and dangerous undertaking. Very different 
is the case when the enlarged gland is removed entire, or in its 
two primitive divisions. Here the haemorrhage is astonishingly 
slight, and is readily controlled by the hot douche; but where 
the substance of the prostate is divided the haemorrhage is per- 
sistent and free. The removal of a pedunculated intravesical 
outgrowth, already referred to as a proper procedure under 
many circumstances, is not open to these objections. Its blood 
supply is derived from the pedicle, not from all surrounding 
tissues, as is the case with the prostatic tumor deeply imbedded 
in the gland, and its removal is safely accomplished by dividing 
its base. 

The results of McGilPs operation in the hands of various 
well-known surgeons may be seen in the following table. 

McGILL'S OPERATION. 

Mortality 
Operator. Cases. Deaths. Per Cent. 

Armstrong [8] 9 4 44-44 

Fuller [92] 5 o 0.0 

Horwitz [126] 5 1 20.0 

MacGowan [154] 21 5 23.8 

Thorndike [227] 9 1 11.11 

49 " 22.45 

Belfield in 1890 collected 88 cases of Mc Gill's operation 
with 12 deaths, a mortaity of 13.6 per cent.; and Moullin in 



212 Radical Treatment. 

1892 collected 94 cases, with 19 deaths, or 20.2 per cent, mor- 
tality. 

There is no dispute as to the fact that the total suprapubic 
prostatectomy advocated by Freyer is a preferable operation to 
the form of prostatectomy formerly employed by McGill; even 
those surgeons who assail the former's claim to originality 
acknowledge the advantages of the method employed. I was 
myself formerly an advocate of the perineal as the preferable 
operation, because of the difficulties and dangers attendent upon 
McGill's suprapubic method; but when I saw Mr. Freyer' s ex- 
cellent results, and appreciated the force of his arguments, I was 
emboldened to attempt a similar operation, and was greatly 
surprised at the simplicity of the technique, and at the pleasant 
convalescence of the patient. This ease of performance is another 
argument in favour of the suprapubic route. For although mere 
facility of execution by the surgeon is in itself no valid argument 
in favour of one operation rather than another, provided this 
other would secure better results and entail less danger to the 
patient, yet in Freyer' s operation the ease consists not alone in 
mechanical execution, but in rapidity of performance, less dis- 
tortion of neighbouring parts, and a shorter convalescence; all 
of which are factors of much importance in old prostatics. 

As seen from Watson's tables, quoted above, the danger to be 
apprehended from uraemia is about equally great in the supra- 
pubic and perineal operations, while that from sepsis is less than 
half as great in the former. On the other hand, the suprapubic 
operation produces greater shock, and these patients are slightly 
more liable to pulmonary complications. (In my own experience 
shock in the suprapubic operation has been comparatively slight.) 
But when we place against these objections the final results, as 
shown in the first table, where we see that ninety per cent, of the 
suprapubic operations are classed as good results, and two-thirds 
as absolute cures, it seems to me that its superiority is evident. 
Mr. Freyer states that he has been so happy as to secure a per- 



Choice of Operation. 213 

feet urinary recovery in every case; I have myself not been so 
fortunate. For although my results have been better than when 
I employed the perineal operation exclusively, yet in a few cases 
slight urinary difficulty (frequency and burning) has persisted. 
Yet as is evident from Watson's third table, evil consequences, 
such as fistula, incontinence, and so forth, are least apt to follow 
the suprapubic operation. 

The perineal operation, as I have already stated, I think, 
with Moullin [177] and other surgeons, is best confined to those 
cases where the prostate is small, fibrous, and sclerosed; where 
the removal of the floor of the prostatic urethra and the main 
part of the lateral lobes of the prostate will lower the vesical 
orifice sufficiently to make a clear water-way; and where there 
is little chance of the only portion of the prostate left (the superior 
commissure) subsequently enlarging and causing renewed ob- 
struction. Where the prostate is of the character described it 
is usually impossible, or at all events extremely difficult, to enu- 
cleate it from within its sheath; and a more or less exact dis- 
section is required. To accomplish this through a suprapubic 
wound is nearly impossible, since the prostate is at such a dis- 
tance from the surface; but when it is well drawn down into 
the perineum by tractors of some variety, such a dissection may 
usually be accomplished. I have not myself found it necessary 
to resort to the elabourate technique and extensive dissection 
employed by Albarran [2], Proust [196], and Young [261], be- 
lieving, with Goodfellow [98] and Syms [221], that everything 
requisite can be accomplished through a straight median incision. 
Yet did I expect to remove the entire prostate through the peri- 
neum in a case where its enucleation was impossible, and dis- 
section was required, I should be inclined to adopt a transverse 
or A-shaped incision, so as to widely separate the rectum from 
the anterior structures by transverse division of the perineal centre 
and the " recto-urethral muscle," and thus bring the whole field 
of operation before my eyes. I am not fond of dissecting with 



214 Radical Treatment. 

a knife or scissors except where my dissection is in full view. 
But, as I said before, it is usually quite sufficient to remove so 
much of the prostate as can be readily reached through the 
median incision. 

As to the preservation of the ejaculatory ducts, I regard 
this as entirely unnecessary. As shown in a former chapter, 
it is extremely improbable that semen without the admixture 
of prostatic fluid is fertile; and the destruction of these ducts 
need not of itself cause impotence. Impotence often exists be- 
fore the operation; and although it has been stated that removal 
of the prostate may restore sexual potency, yet of this I am not 
very sanguine; but I do know of one patient, whose prostate I 
enucleated by Freyer's method, who told me that he was able 
to have pleasure from sexual intercourse after convalescing from 
the operation, which before the operation had been painful to him. 

It will be seen from the preceding paragraphs that I prefer 
suprapubic prostatectomy as the radical treatment for the major- 
ity of patients. Indeed, since first adopting this method I have 
not seen a case in which it did not seem preferable to the peri- 
neal operation; but I recognize the fact that there are cases 
where the perineal is to be peferred, and when I encounter such, 
I shall not hestitate to adopt the latter procedure. 



CHAPTER XII. 

TECHNIQUE OF OPERATIONS, INCLUDING THE PREPARA- 
TION OF THE PATIENT, WITH THE AFTER- 
TREATMENT. 

Preparation of the Patient. — The preparation of the patient 
is essentially the same no matter by which route — suprapubic 
or perineal — the prostate is to be removed. 

These are not emergency operations, and the patient should 
be under preparation for the operation for at least forty-eight 
hours. In the case of many patients the surgeon will have been 
in attendance for weeks or months ; but even such patients re- 
quire further preparation than mere surgical attention. This 
preparation should be both general and local. As constitutional 
treatment it is well to pay special attention to the condition of the 
kidneys, the heart, and the lungs. 

In treating the kidneys the state of the urine must be con- 
sidered. It should be acid, fairly clear from pus, mucus, blood, 
etc., and should be excreted in quantities not too far removed 
from the normal. An exceptionally low percentage of uraea will 
render the operation much more dangerous unless the total 
quantity of urine excreted is correspondingly increased; yet I 
have successfully removed the prostate of a patient in whom there 
was present only eight-tenths of one per cent, of uraea. It should 
be constantly borne in mind that the total quantity of urine passed 
in twenty-four hours should be measured, and the percentage of 
uraea calculated from this quantity. All these matters may have 
been successfully attended to before any operation was decided 
upon, as advised under palliative treatment; but particular at- 
tention to these points must be paid during the day or so im- 
mediately preceding the operation. 

For the heart it is usually well to prescribe a course of strych- 

215 



216 Operative Technique. 

nine or digitalis, even if the cardiac action is not noticeably ab- 
normal. The shock of the operation is a strain on even a well- 
preserved heart; but it may be much lessened by getting the 
heart into training previous to the operation. In my hospital 
experience I have found that Resident Physicians are only too 
apt to overdose the patient with strychnine after the operation, 
while omitting it in the preparation. 

The lungs should of course be free from acute disease, such 
as bronchitis; and where a more or less chronic or subacute 
bronchitis, hypostatic congestion, asthma, or emphysema is pres- 
ent, special care should be exercised in the administration of the 
anaesthetic, as well as in the prevention of chilling or exposure. 
For such patients I prefer chloroform to ether. Drugs directed 
to the condition of the lungs are usually of little use, but if the 
heart be treated the lungs may be benefitted indirectly. 

It is not usually advisable to confine the patient to bed even 
on the day immediately preceding the operation, unless he is 
already bedridden: it is sufficient for him to regulate his life 
with the utmost care for two or three days, confining himself to 
the house, and taking special precaution to break no well-estab- 
lished habit of life. On the morning of the operation he should, 
of course, remain in bed. It is well to have the services of a 
trained nurse for at least twenty-four hours before the operation. 

The alimentary canal should be well cleaned out by a brisk 
cathartic given in the afternoon before the operation, and the rec- 
tum should be emptied by enema on the morning of the operation. 
Should the afternoon cathartic not act, it is to be repeated early 
in the evening or on the following morning, before the operation. 
If, as has been advised, the patient has been in the habit of taking 
a cathartic about once in a week or ten days, no difficulty will be 
experienced in thoroughly emptying the intestinal tract without 
the use of drastic purges. Indeed, the routine administration of 
cathartics to patients as practised in some hospitals in preparation 
for operation, is debilitating in the extreme; the patient being in 



Preparation of the Patient. 217 

no fit condition to undergo a serious operation after a sleepless and 
frequently disturbed night. I think that one good free movement, 
which may, as a rule, be procured by one dose (half an ounce) of 
epsom salts or of castor oil, together with an enema on the morn- 
ing of operation, will evacuate the intestinal tract quite sufficiently ; 
and I can see no sense in repeatedly purging patients until ex- 
haustion is produced. 

The diet for the few days preceding the operation should be 
light; and the supper the evening before may best be confined 
to fluids (milk, broth, gruel, milk-toast, etc.), and perhaps a 
soft-boiled or poached egg, with a little stale bread. If the 
laxative is taken before supper, such a meal will leave compara- 
tively little residue, and this may be removed by an enema in 
the morning. Plenty of fluid may be taken up to within about 
six hours of the operation. This will flush out the kidneys, and 
help to refill the vascular system, which is always somewhat 
depleted if a saline purge is employed. If the operation is not 
to take place until afternoon, a light breakfast (broth or gruel) 
should be allowed, but this should be omitted when the opera- 
tion is to be in the morning. 

The extent of local preparation will vary somewhat with the 
patient. The lower class patient had best be given a tub bath, 
warm, in the afternoon of the day before the operation; but in 
a patient who is in the habit of bathing himself, such active 
cleansing will not be required. Some patients will not become 
decently clean until the bath has been repeated on several suc- 
cessive days, and will reacquire dirt at the least opportunity. 
When the demands of ordinary cleanliness are satisfied, the pa- 
tient may rest until morning, when he should be shaved. It is 
always well to prepare for both suprapubic and perineal wounds, 
as some unforeseen complication may make it advisable to open 
in a place not anticipated. Hence the pubic and- perineal hair 
both should be shaved; the skin of the abdomen, the groins, the 
genitals, the perineum, and the anterior and inner surfaces of the 



218 Operative Technique. 

thighs, should all be thoroughly washed first with turpentine, 
then with green soap and hot water, then with seventy per cent, 
alcohol, and finally with corrosive sublimate solution (i: iooo). 
A dry sterile dressing should then be applied to the abdomen 
and perineum, and should remain in place until removed on the 
operating table. 

Proust has laid especial emphasis on the propriety of prepar- 
ing the urethra of every patient who is about to undergo a pros- 
tatectomy. He thinks it extremely important to dilate the canal 
by the passage of sounds for some days before the operation, so 
as to insure the earliest possible restoration of urethral urination. 
But while I have no hesitation in dilating any strictures that 
may exist, yet I think that the routine dilatation of urethras 
which are apparently normal except for the prostatic obstruc- 
tion is an unnecessary and therefore an undesirable performance. 

We may then summarize the preparation for a prostatectomy 
as follows: 

For two or three days regulate the patient's habits, heart, 
and kidneys. 

On the day before the operation give a bath in the afternoon ; 
give a cathartic' before supper; for supper give only semisolid 
food ; the bowels should be opened during the late afternoon or 
early evening. A good night's rest should follow. Fluid may be 
taken as desired until six hours before the operation. 

On the morning of the operation an enema is to be given. 
Then shave and surgically cleanse the abdomen, perineum, etc. 
Apply the dressing, and wait for the operation. 

Anaesthetic. — For the majority of these patients I think 
chloroform is to be preferred to ether. Especially is this the 
case when there is any pulmonary lesion. I am in the habit of 
commencing its administration myself, and only transferring 
this task to my assistant when the patient is thoroughly under 
its influence. I find that this method encourages the patient, 
and it obviates the possibility of any blame attaching to my 



PLATE LXXVI. 












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Suprapubic Prostatectomy. 219 

assistants should any accident occur. I say this, because I am 
perfectly well aware that chloroform is a dangerous drug. Wiener 
[250] advocates the use of laughing gas (hyponitrous oxide) in 
Freyer's operation, and has employed it seven times without a 
death. Goodfellow [98 a] has employed spinal anaesthesia exclu- 
sively in his later operations. 

Suprapubic Prostatectomy. — The patient, being well 
covered with blankets and sterile sheets, is to have a soft-rubber 
catheter passed into his bladder. If such a catheter cannot be 
introduced the surgeon should select that instrument which from 
his previous experience with that patient he regards as most 
likely to succeed in passing the obstruction. Through this cathe- 
ter the bladder is to be evacuated, and rinsed out with hot boric 
acid or saline solution (over ioo° F.) two or three times, or until 
the fluid returns clear. About four ounces of this fluid should 
remain in the bladder, the catheter being clamped to prevent its 
regurgitation. The disadvantages of distention with air have 
already been referred to. (See page 170.) The patient is then 
raised into a moderate Trendelenburg position — about thirty 
degrees — and the suprapubic region uncovered. The surgeon, 
standing on the right of the patient, then makes his suprapubic 
incision, which in thin patients need not exceed two inches in 
length ; but must be increased up to a limit of perhaps five or six 
inches where the abdominal wall is extremely fat. This incision, 
which I make to one side or other of the linea alba, usually to the 
right side, exposes the sheath of the rectus (Plate lxxvi). 
Its lower end should be at the symphysis pubis, neither above 
nor below. If annoying bleeding occurs from veins or arterioles, 
these should be clamped; the haemostatic forceps may usually 
be removed as soon as the bladder is exposed, and will there- 
fore not be in the way in the subsequent steps of the opera- 
tion. Vessels of any size, which are rarely met with near the 
middle line of the abdomen, had best be ligated at once. 

The sheath of the rectus is then opened, and its fibres sepa- 



220 Operative Technique. 

rated, longitudinally, by the handle of the scalpel, from their 
pubic attachment below, up to but not quite as far as the skin 
incision extends (Plate lxxvii). I regard this lateral incision 
as of distinct advantage in decreasing the chances of the for- 
mation of a permanent fistula. The wound thus made tends to 
close spontaneously as soon as the drainage-tube is removed; 
and although post-operative hernia in this situation is unusual, 
it is by no means unknown. 

The transversalis fascia and preperitoneal fat are then divided 
with the scissors in the line of the skin incision; any decrease in 
the length of the incision should be made at the expense of the 
upper end of the wound; that is to say, the surgeon should aim 
to work down on the anterior wall of the bladder, not up towards 
its peritoneal surface. The layer of vesical fat will next be 
exposed, lying below the prevesical reflection of the peritoneum. 
The surgeon may then either pass the fingers of his left hand 
down behind the pubis to the pubo-prostatic ligaments, and draw 
this layer of fat bodily up towards the abdominal end of the 
wound, or snip through it in the line of the original incision, with 
his blunt-pointed scissors. I prefer the latter course. Retrac- 
tors may be applied to each side of the wound, and aid by keep- 
ing the structures to be divided fairly taut. Any haemostatic 
forceps which were used to clamp bleeding points in the abdomi- 
nal wall may now be removed, since it will be found that such 
vessels have ceased to bleed. 

The large veins in the prevesical fat should be avoided if 
possible. If the surgeon divides any, it is well to ligate them 
at once. If possible, they should be ligated in two places before 
being cut, the division between two ligatures maintaining the 
wound dry, and enabling the surgeon to see clearly the field of 
operation. 

The prevesical fold of peritoneum is rarely seen in these 
operations; the Trendelenburg position, even without the dis- 
tention of the bladder, allowing it to recede above the upper 



PLATE LXXVII. 




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Suprapubic Prostatectomy. 221 

limits of the wound. If it is seen, it is, as a rule, easily recog- 
nized, both by the typical appearance of peritoneum seen any- 
where, and by the fact of its being a transverse fold; and it is 
easily detached from the bladder by blunt dissection. Should 
it unfortunately be opened, it should at once be sutured, and 
the perineum should be drained at the close of the operation. 

The bladder is recognized by its blue appearance and its 
consistency. If any doubt exists as to its identity, it will be 
sufficiently manifested by injecting more fluid through the catheter. 
There are often large and turgid veins on its surface. 

When the bladder is thus exposed, two retention sutures may 
be passed through its outer coats, about a half or three-quarters 
of an inch apart, equidistant from the proposed line of incision, 
and in its upper third. I formerly passed these sutures through 
the whole thickness of the abdominal walls as well, and let them 
remain at the conclusion of the operation, thinking thus to lessen 
the dangers of extravasation into the space of Retzius; but I 
think the likelihood of this danger is overestimated, and I have 
had more fear of causing an injurious anteflexion of the bladder; 
so that I no longer intend these for permanent sutures, but merely 
to act as guys during the enucleation of the prostate. If it is 
difficult to pass these sutures, on account of the depth of the 
wound, one may be made to suffice by placing it in the line of 
the incision, at the upper angle of the wound. Indeed, in my 
later operations I have found it quite sufficient to steady the 
bladder with a tenaculum until the finger reaches the prostate 
(Plate lxxviii), and then to remove the tenaculum and let the 
bladder fall back into the pelvis during the enucleation. 

The bladder, being thus securely fixed in the wound, is to 
be opened by an incision made towards the pubic symphysis, 
and extending below it. This incision in the bladder walls should 
never be made upwards, as not only might the peritoneum be 
opened, but a coil of intestine wounded as well. It is inadvisable 
to make an incision of more than an inch or an inch and a half 



222 ^ Operative Technique. 

in length in the bladder wall, and the left index finger of the 
surgeon should follow the knife in, so as to palpate the inner sur- 
face of the bladder, the prostate, and the urethra, before all the 
fluid has escaped. A much more accurate idea of the relations 
of the various parts is attained when the bladder is distended. 

The table may now be replaced in the horizontal position. 

The finger should first seek to recognize the position of the 
urethra with its contained catheter. The outlines of the prostate 
can next be determined, the presence of calculi detected, and 
plans made for the further continuance of the operation. Any 
calculi present should first be removed, with forceps or scoop. 
If no guy sutures have been retained in the bladder it is best 
not to remove the finger from its interior until the completion 
of the operation, as its reintroduction may be difficult if the 
abdominal wound is deep. If a large calculus is found, the in- 
cision in the vesical wall may need to be enlarged before the stone 
can be safely removed; but with skill even large stones may be 
removed through an incision of little more than an inch. In very 
many cases retractors must be employed to draw apart the sides 
of the abdominal wound and the bladder wall before the pros- 
tate can be satisfactorily exposed. At times two other retractors 
may be used to advantage, increasing the field of operation 
in its longitudinal diameter (Plate lxxix). 

If a pedunculated prostatic outgrowth acting as a ball-valve 
against the vesical orifice of the urethra is found, it should be 
twisted off with the fingers, or its pedicle should be cut through 
with scissors or bladder forceps. If no other urethral obstruc- 
tion exists, — a fact which can readily be determined by partially 
withdrawing and reinserting the catheter, — the operation may now 
be terminated, and the bulk of the prostate be left untouched. 
Often, however, there will be found similar prostatic tumors pro- 
jecting into and obstructing the urethra, which are not evident 
from the cavity of the bladder; hence the great importance of 
making sure of the patulous condition of the urethra before de- 



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Suprapubic Prostatectomy. 223 

riding to conclude the operation by a partial prostatectomy. This 
is a point which has been much insisted upon by Belfield [18], 
and is probably the explanation of the failure of so many of the 
early suprapubic prostatectomies to effect a permanent cure. 

If no such pedunculated outgrowth exists, or if a complete 
prostatectomy is indicated even after its removal, an incision, 
long enough to admit the end of the index finger, should be made 
over the more prominent of the two lateral lobes. This incision 
should run parallel with the urethra, and is usually most con- 
veniently made with a pair of scissors; I have, however, on 
numerous occasions, simply scratched through the vesical mucous 
membrane with my finger-nail. The surgeon then introduces 
the middle and index fingers of his right hand, gloved, into the 
patient's rectum, passing his arm beneath the flexed thigh; and 
placing his thumb against the perineum, makes counterpressure 
on the prostate, and raises it up towards the enucleating finger. 
The larger and more adenomatous the prostate, the easier it is 
for the surgeon to find the natural line of cleavage which exists 
between the prostatic capsule and its sheath. It is not safe to 
go too wide of the prostate in the endeavour to remove it all. 
All of it will be removed, except perhaps here and there a flake 
off the outer surface of its capsule, by clinging close to the adeno- 
matous organ rather than by going off on voyages of discovery 
into the sheath. In other words, the prostate is to be removed 
from its sheath, not the sheath from the prostate (Plate lxxx). 

The finger should first pass to the outer side of the lateral 
lobe first attacked. In this situation the attachment of the pros- 
tate to its sheath is least dense. Then the finger should cau- 
tiously but not timidly work down and under the lateral lobe, 
towards the neighbourhood of the posterior commissure and the 
ejaculatory ducts. Next the posterior and inferior surfaces are 
separated from the sheath; and, finally, when the lobe is pretty 
well outlined, the finger may pass along the lateral and inferior 
surfaces to the apex, and free it from the triangular ligament. 



224 Operative Technique. 

At times the lateral lobe first attacked may come away alone, 
leaving the urethra still attached to the other lateral lobe. More 
often in my experience the original incision through the vesical 
mucous membrane has torn larger during this enucleation, and 
the vesical orifice of the urethra has become entirely detached 
by the extension of the tear across the trigone of the bladder. 
Then the enucleating finger will pass across to the second lobe, 
almost invariably as it does so tearing loose the ejaculatory ducts 
from their union with the urethra; and finally, having completed 
the enucleation of this second lobe, will find the prostate fully 
detached from all its surrounding structures except where the 
urethra annexes it to the triangular ligament. 

At this stage of the operation either one of two things happens 
— the urethra slips out from the centre of the prostate, remain- 
ing still attached to the triangular ligament, and hanging loose 
like the empty finger of a glove (with its end cut off) in the cavity 
from which the prostate has been enucleated; or, which I think 
is more frequently the case, the urethra tears off at the triangular 
ligament, and its prostatic portion is removed entire in the centre 
of the prostate. I do not see how it is possible, and know it has 
never been so for me, to leave the prostatic urethra, with the 
attached ejaculatory ducts in place, annexed at both ends — 
anteriorly to the triangular ligament, posteriorly to the bladder 
wall. I have several times been able to remove the entire pros- 
tate, including of course its urethra, through the one original 
incision made through the vesical mucous membrane ; but where 
the organ is very large this cannot be satisfactorily done, and a 
second incision, comparable to the first, must be made over the 
other lateral lobe. If the anterior commissure of the gland 
gives way during these manipulations it is theoretically possible 
to swing the whole prostate (which is then merely an organ with 
the urethra lying in a groove on its upper surface) across beneath 
the urethra, and to deliver it entire through one or other of the 
incisions in the mucous membrane of the bladder; but even thus 



PLATE LXXX 







Cfl 



3 P 



X J£ "" 
X c s 






PLATH LXXXI. 




Appearance of Parts After the Completion of Freyer's Operation, Showing the 
Remnants of the Prostatic Urethra, Attached Below to the Triangular 
Ligament and Above to the Bladder. Between the Divided Ends of the 
Urethra are seen the Remains of the Ejaculatory Ducts. — (Walker.) 



Suprapubic Prostatectomy. 225 

I cannot see how the attachment of the ejaculatory ducts can be 
preserved, though it is theoretically possible for the prostatic 
urethra to remain intact, traversing the cavity from which the 
prostate has been removed much as a resistant artery traverses 
a phthisical cavity. 

The condition of the parts which is probably the most usual 
is shown in Plate lxxxi taken by Mr. J. W. T. Walker from one 
of Freyer's patients who died two hours after the operation. Here 
two tongue-like processes can be seen, representing the remains 
of the urethra, extending downwards from the vesical mucous 
membrane, and upward from the triangular ligament; while be- 
tween and below these can be seen the ejaculatory ducts, torn 
loose from all connection with the urethral floor. 

When the prostate has thus been delivered into the interior 
of the bladder, the tissues left between the rectal and vesical 
hands are felt to be very thin, and no trace of remaining pro- 
static substance can be detected. The hand is then withdrawn 
from the rectum, the glove removed, and the prostate extracted 
from the bladder with the ringers or suitable forceps. The more 
adenomatous the prostate, the more compressible it will be, and 
the vesical incision should not be enlarged until attempts to re- 
move the prostate have failed. 

The cavity from which the prostate was enucleated will now 
be found to have become amazingly reduced in size, both by 
active contraction, and by pressure from the surrounding struc- 
tures. Bleeding may be free, but is usually only moderate in 
amount, and readily controlled by the hot douche, which is to 
be freely applied through the suprapubic wound. 

Should this fail to control the haemorrhage another plan must 
be tried. Often by gauze pressure well directed against the 
oozing area the bleeding may be checked. But if the haemor- 
rhage persists, or in case of secondary haemorrhage, continuous 
pressure must be applied. It has been advised to apply this 

in the following way: a number of layers of gauze, of suitable 
16 p 



226 Suprapubic Prostatectomy. 

size, are stitched together at their centre; the end of the suture 
is left long, and is attached to the intravesical end of the catheter 
which has been lying in the urethra throughout the operation, 
or which is to be introduced if not already in place. By with- 
drawing this catheter, the thread will follow, and will press the 
attached gauze firmly against the vesical orifice of the urethra. 
Care should be taken that this gauze does not occlude the ure- 
teral orifices. 

This method of haemostasis has always seemed to me to be 
objectionable. When the gauze becomes soaked through with 
urine there is risk of its acting merely as a sponge, and thus allow- 
ing the blood to ooze through its meshes. A safer plan, I think, 
is to pack with gauze the cavity from which the prostate has 
been enucleated, and then to suture over the packing the 
mucous membrane forming the roof of the cavity from which 
the prostate has been removed, of course leaving an end of the 
gauze long, to come out through the suprapubic wound, and 
facilitate its removal. The suture material should be catgut, 
and the packing could remain in place until it became loosened 
by the absorption of the catgut — usually in from four to five days. 
I have recently adopted this plan with the most gratifying results 
in a case where furious bleeding followed the removal of an ad- 
herent prostate by Freyer's method. Of course, if this method 
were adopted for the control of secondary haemorrhage, the patient 
would have to be anaesthetized and the suprapubic wound en- 
larged. For secondary oozing which is not marked irrigation 
with hot water will usually be found an efficient haemostatic; 
or a solution of adrenalin chloride (i : 10,000) may be used. It 
is certainly well to try the effect of milder measures first, and not 
resort to packing injudiciously. 

As soon as the prostate is extracted from the interior of the 
bladder, the urethral catheter, if not previously withdrawn, is 
to be removed; and a long rubber tube of large calibre — one- 
quarter or three-eighths of an inch — passed into the bladder 



Plate LXXXII. 




— 

U 3 



Rj 



bo 

7i 






to 

II 

< — -J 



O w 

o 

Jj; 

rf o 
r C 

o '5b 



Dressing of the Wound. 227 

through the suprapubic wound. This tube should be about two 
feet long, and I am careful to have it open not only at the end, 
but also to have large eyes on its sides near the vesical end, since 
should the bladder wall come in contact with the end opening, 
all drainage would be effectually prevented. To further obviate 
the likelihood of any such obstruction I do not pass the tube 
far into the bladder, merely making sure that it fulfils its purpose 
as a drain; and under no circumstances dismissing the patient 
from the table until it is evident that the tube is clear of all clots 
and other obstructions, and the urine or intravesical fluid can be 
seen distilling from its further end drop by drop. 

The anaesthetic may be stopped as soon as the irrigation of 
the bladder is commenced; and by the time the patient is in his 
bed he should be fairly conscious of his surroundings. 

The suprapubic tube is held in place by a stitch through 
the skin; and the angles of the wound, when this is large, may 
be sutured, but if the urine is foul no sutures at all should be 
employed; but as the parietal peritoneum has a tendency at 
times to prolapse into the upper angle of the wound, one suture 
in this situation may be necessary. Separate catgut sutures 
should be used for the sheath of the rectus muscle and for the 
skin. The dressing, of sterile gauze, cut so as to fit around the 
tube, and each piece overlying that beneath in an imbricated 
manner, should be copious, and may be reinforced with absor- 
bent cotton. Thus whatever urine is not carried off by the tube, 
but leaks out along its sides, will be quickly absorbed in the 
dressings, and will not trickle over the patient's buttocks and 
clothing. 

The further end of the tube must be connected with a suit- 
able receptacle below the level of the patient's bladder, so that 
the syphonage may be continuous. If this detail is attended to 
there will be no necessity for the employment of a vacuum pump, 
as described by W. G. Richardson [199] in his recent essay. The 
urinal into which this suprapubic tube drains should be partly 



228 Suprapubic Prostatectomy. 

filled with some antiseptic or deodorant solution, sufficient in 
depth to cover the end of the tube ; and in calculating the amount 
of urine excreted the quantity of fluid already in the urinal must 
be subtracted. 

The suprapubic dressing may be renewed as often as it be- 
comes saturated. As a rule, twice daily is quite frequently 
enough. 

Should there be much shock after the operation, suitable 
stimulation must be administered; but it is of more importance 
to prevent shock, and for this purpose nothing is so efficacious 
as external heat. The patient may be surrounded with hot- 
water bags throughout the operation in many cases with the 
greatest advantage, or, better still, be placed on a hot- water bed. 

On the day following the operation, and once each subse- 
quent day, the bladder is douched through the suprapubic wound. 
I do not retain a catheter in the urethra, nor do I pass one to 
irrigate the bladder, after the operation, until this can no longer 
be accomplished through the suprapubic wound. But if an 
ammoniacal state of the urine developes I think great ad- 
vantage is to be derived from douching the bladder through the 
urethra, the fluid draining off by the suprapubic wound. For 
the purpose of intravesical douching in these cases it is usually 
quite sufficient to introduce the nozzle of the syringe into the 
urinary meatus, there being no necessity to pass a catheter into 
the bladder, since the passive resistance of the urethra can readily 
be overcome by fluid pressure. The suprapubic tube may usually 
be removed on the second day after the operation, and the patient 
encouraged to pass his urine in the natural way; but there is 
no objection to leaving the tube in place for five or six days if such 
a course should seem desirable. Voluntary micturition com- 
monly returns earlier after this operation than after that by the 
perineal route; and, as there is no fear of a sinus persisting below, 
the patient may be propped up in bed on the fourth or fifth day, 
and be allowed to sit in a chair at the end of a week or ten days if 



PLATE LXXXIII. 




Suprapubic Operation. 
Drainage-tube and dressing in place. 



After-treatment. 229 

his general health permits. Indeed, as soon as the patient feels 
able to be out of bed, no matter how few days have elapsed since 
the operation, I think he should be allowed to be up. 

Unless something should indicate the existence of urethral 
obstruction, I am not in the habit of passing instruments by 
this route as long as the suprapubic wound remains available 
for the daily irrigation of the bladder. Should, however, this 
fail to show any signs of closing in the second week, I think 
it proper to sound the urethra, so as to ensure against the for- 
mation of strictures. I do not regard it as at all impossible 
for strictures to form as a result of the removal of the prostatic 
urethra; but I think the injudicious resort to instrumentation 
might very well render their formation more probable. When, 
however, the suprapubic wound has closed, which it commonly 
does in the third or fourth week, I consider it safe to irrigate the 
bladder through the urethra ; and this, I think, should be done at 
least once a week for some months after the operation, unless the 
urine sooner becomes normal. In any case, the regular passage 
of a full-sized sound once a week for some months after the opera- 
tion can be productive of no harm, and should, I think, be ad- 
vocated in most cases, especially where a tampon has been em- 
ployed for the control of haemorrhage. 

Some surgeons have found that the suprapubic wound is apt 
to reopen once or twice before finally healing; but this has not 
been my experience. 

Secondary haemorrhage and the means of controlling it have 
already been referred to; but I think it important to call atten- 
tion]^ looseness of the bowels as a cause of this complication. 
Every time the bowels are opened the granulating wound is dis- 
turbed, and the liability to bleeding increased. Hence diarrhoea 
should be avoided, and where slight oozing persists it may be 
well to try the effect of opium or paregoric before more strenuous 
measures are resorted to. 

The patient's usual diet and mode of life may be resumed as 



230 Perineal Prostatectomy. 

rapidly as his convalescence will permit; but he should pay 
particular attention to the state of his kidneys and urine for 
many months after the operation. He should be encouraged 
to drink all the water possible from the instant his stomach 
becomes retentive after recovery from the anaesthetic; this is 
the surest method of preventing uraemic conditions. The ap- 
pearance of hiccough and nausea following the recovery from 
anaesthesia, particularly if a small amount of urine is being ex- 
creted, is indicative of a mild degree of uraemia, and should be 
promptly met by medical measures. It is not my practice to 
resort at once to agents such as calomel, sparteine, caffeine, etc., 
after operation, but to immediately wash out the stomach with 
the stomach-tube, this being a far more effective remedy for hic- 
cough than any antispasmodic drug; I then introduce into the 
stomach one and a half or two ounces of Glauber's salt in con- 
centrated solution. Where the stomach is empty the solution 
soon finds its way into the small intestine, and in a short time 
bowel action is obtained. I have found this of more service 
than any other agent. Should further treatment be required, 
however, rectal, subcutaneous, or intravenous infusions of deci- 
normal saline solution should be employed, and other appropriate, 
treatment should be instituted, as already indicated at page 162. 
Perineal Prostatectomy. — So many variations and modifica- 
tions of this operation are now in use, that a minute descrip- 
tion of each in a work of this kind would be impracticable. All 
the methods employed, however, may be classed in either one 
of two categories — those operations where an elaborate dissec- 
tion is required, as seen in the technique of the French school 
developed by Proust [196], and as modified in this country by 
Young [261]; and those operations where only a partial pros- 
tatectomy is performed, the manipulations being conducted 
through a comparatively small perineal wound. The latter 
is the form of operation which I have employed myself, and which 
is, I believe, that most generally adopted by operators in this 



PLATE LXXXIV. 




Proust's Inverted Perineal Position for Perineal Prostatectomy. 



PLATE LXXXV. 





Perineal Prostatectomy. — {Proust.) 
The transverse perineal incision. 



Goodfellow's Technique. 231 

country. The technique employed by Dr. Goodfellow, as al- 
ready remarked, appears to me to differ in no essential parti- 
culars from that of Mr. Freyer, except that the prostate is re- 
moved through a perineal instead of a suprapubic wound. Dr. 
Goodfellow's [98] own description of his operation is as follows: 
"The usual pre-operative procedures are carried out. . . . 
With the patient in the ordinary lithotomy position, the legs 
held by assistants, the bladder being empty or full as the case 
may be, a lithotomy staff is introduced, the legs then elevated 
somewhat, a median incision from the base of the scrotum to 
the margin of the anus is made, and carried to the membranous 
urethra, which is entered with a straight lithotomy knife and the 
opening extended into the bladder. The finger is then intro- 
duced into the bladder, the staff removed, and the moderate 
flexion of the legs and thighs on the abdomen and the thorax 
increased to as great an extent as possible; then with the op- 
posing hand over the hypogastrium the bladder is depressed, and 
the enucleation, beginning at the beak of the prostate below and 
working upward next to the bladder, or from above on either 
side downward, is carried on, the time consumed for complete 
enucleation rarely being over five or ten minutes, the resulting 
hemorrhage being virtually nothing. The gland may be removed 
entire or lobe by lobe. . . . What becomes of the prostatic 
urethra? has been asked. The answer is that part or all is re- 
moved with the gland, an incident that in no manner seems 
to affect the restoration or the continuity of the urethra, nor the 
power of the bladder to regain and control its functions; nor is 
stricture or occlusion caused. The seminal ducts are not iigated, 
for this seems to me an irrational refinement, especially as many 
of my patients have (so they say) to a greater or less extent 
regained sexual vigor." 

Dr. Goodfellow continues: "The points to be expressly 
emphasized are the position and the incision into the bladder. 
. . . . I do not find it necessary now to use the knife to 



232 Perineal Prostatectomy. 

enter the urethra and bladder. After cutting to the urethra I 
am able with the finger to open it and get into the bladder 
by a boring movement. Then not having a cut through the 
commissure, I enucleate from above instead of from below as 
formerly.' ' 

1. Perineal Prostatectomy. Technique 0} Proust. — Perineal 
prostatectomy as practised by Proust requires a special operat- 
ing table, and special retractors. The patient is placed in the 
" inverse lithotomy position/' so that the perineum is in the 
horizontal plane, its surface looking upward. (Plate lxxxtv.) 
To secure this the patient's lumbar spine and sacrum are placed 
upon an inclined plane of forty-five degrees, and his legs are 
held by special stirrups high in the air, with the thighs fully 
flexed and horizontal. By means of this position it is claimed 
that a very much larger operative field in the perineum is ex- 
posed, since, after division of the recto-urethral muscle, and 
opening of the aponeurosis of Denonvilliers, as will be presently 
described, the rectum and anus can be drawn upward against 
the coccyx and lower bones of the sacrum, making a yawning 
wound. For this purpose a self -retaining retractor is employed, 
and the aid of an assistant may be dispensed with. 

The patient being fixed in the position above described, his 
bladder being empty, and a metal guide or catheter in the urethra 
being held close beneath the pubic arch, so as to draw the bulb 
of the urethra well up out of the operative field, a transverse 
incision is made in front of the anus, with its convexity forwards, 
from one ischiac tuberosity to the other. The attachment of 
the external sphincter ani to the perineal centre is then divided, 
and the dissection continued posterior to the transverse perineal 
muscles. By drawing the anus backwards, that is, towards 
the operator, the recto-urethral muscle is put upon the stretch 
(Plate lxxxvi). This is a somewhat indefinite structure which 
consists of muscular and fibrous tissue passing from between the 
layers of the triangular ligament backwards to the rectum, by 



PLATE LXXXVI, 





Perineal Prostatectomy. — (Proust.) 
After dividing the skin, and separating the insertion. of the sphincter ani from the 
perineal centre (which is raised by forceps in the right hand of an assistant), the recto- 
urethral muscle is exposed, and is now being divided with scissors, close to the mem- 
branous urethra. 



PLATE LXXXVII. 




Perineal Prostatectomy.— (P>w/s/.) 

The recto-urethral muscle has been dhided, allowing the rectum to fall away from the 

anterior structures, and opening the "espace decollable relro-prostalique." 



PLATE LXXXVIII 




Perineal Prostatectomy. — (Proust.) 

The two index finders of the operator are introduced between the two layers of the apo 

neurosis of Denonvilliers, and enlarge the "espace decollable relroprostatique." 



PLATE LXXXIX. 





Perineal Prostatectomy. — {Proust.) 
The sheath of the prostate (the anterior layer of the aponeurosis of Denonvilliers) has 
been opened, and the surgeon's finger now detaches the sheath from the prostate by blunt 
dissection The prostatic tractor sometimes employed by Proust is not shown in this 
illustration. 



Technique of Proust. 233 

their insertion into which is produced the acute flexure of this 
canal just within the anus. 

The recto-urethral muscle must next be divided. This is to 
be done with a pair of scissors, snipping through these fibres 
close to the membranous urethra. If great care is not exercised 
to keep close to the membranous urethra, but without opening 
it, the dissection will be made below the posterior layer of the 
aponeurosis of Denonvilliers, between it and the rectum, instead 
of ^between the two layers of this structure (Plates xv, lxxxvh), 
where is found the "espace decollable retro- prostatique." 

As soon as the recto-urethral muscle has been divided in the 
required place, the rectum will fall away from the anterior struc- 
tures, and the two layers of the aponeurosis of Denonvilliers may 
be readily separated with the two index fingers (Plate Lxxxvin). 
The rectum will now appear like a loop of intestine floating free in 
the peritoneal cavity, being covered by the posterior layer of this 
aponeurosis, while the anterior layer still conceals the prostate 
and seminal vesicles from view. It is to be recalled that the 
aponeurosis of Denonvilliers is really an obliterated sac of peri- 
toneum. (See pages 24 and 31.) 

When the "espace decollable retro-prostatique" is thus widely 
opened, the special retractor is inserted, and screwed up so as 
to hold the rectum and anus against the sacrum and coccyx. 

Beyond the anterior layer of the aponeurosis of Denonvilliers 
the prostate can now be indistinctly felt, floating away as soon 
as it is touched. Proust now opens the urethra, at the apex of 
the prostate, posterior to the triangular ligament, not between 
its layers; and after withdrawing the guide, inserts into the 
bladder through the urethral incision a special tractor — 
DePezzer's — which is very similar to that employed by Young, 
and represented in Plate xciv. 

The prostate being thus steadied by spreading the blades of this 
tractor over its vesical surface (Plate xcv, Fig. 1), the sheath of 
the prostate (the anterior layer of the aponeurosis of Denonvilliers) 



234 Perineal Prostatectomy. 

is to be opened with scissors, parallel to the urethra. The finger 
of the surgeon is then inserted between this layer of fascia and 
the capsule of the prostate, which is thus exposed on its rectal 
aspect; and the surgeon proceeds to detach the prostate from its 
sheath by the finger (Plate lxxxix) . He detaches it first along the 
side of one lateral lobe, then below, and from the vesical aspect, and 
finally in front, above, and close to the pubis. This enucleation 
should be done deliberately, and with the most painstaking 
thoroughness. Proust says that time apparently lost at this 
stage of the operation will at a later stage be found to accelerate 
matters considerably. When the prostate is thus freed of all 
its attachments, except those to the urethra, and to the ejacu- 
latory ducts, the operation may proceed, but not before. The 
prostatic tractor is then removed. 

The wound in the urethra is now to be enlarged. This is 
accomplished by splitting its floor from the apex of the prostate 
to but not into the neck of the bladder (Plate xc). This cut 
hemisects the prostate as well; and each lobe in turn is then 
dissected off the lateral and upper aspects of the prostatic urethra 
by means of scissors, the index finger of the left hand being 
placed on the mucous surface of the prostatic urethra if neces- 
sary as a guide (Plate xci). Proust ligates the ejaculatory 
ducts, thinking that by this means orchitis is less apt to occur. 
He removes each lateral lobe entire, advising against morcelle- 
ment, which he considers necessary only when the gland is 
extremely friable and comes away in pieces of its own accord. 
He follows Albarran in the practice of resecting the floor of 
the prostatic urethra when this part of the canal is unduly 
dilated. 

When an intravesical projection, more or less pedunculated, 
is present, he delivers this through the prostatic urethra, and 
accomplishes its removal just as if he was working through a 
suprapubic wound; or if the pedicle is too short or too broad 
to allow of its delivery in this manner, he works up from the 



Plate XC. 





Perineal Prostatectomy.— (Proust.) 
Hemisection of the prostate along the floor of the urethra. 



PLATE XCI, 




Perineal Prostatectomy.— (Pxoust.) 

Each lobe ot the prostate in turn is dissected free from the sides of th 



e prostatic urethra. 



PLATE XCI1. 




s> 




Perineal Prostatectomy. — (Proust.) 
The ejaculatory ducts have been ligated, and the urethra is now being sutured. 



Technique of Proust. 235 

lower surface of the bladder, and enucleates the mass without 
opening the vesical mucous membrane. 

The operation is completed by passing a rubber tube or 
catheter through the penis into the bladder, and another catheter 
to the bladder through the perineal wound. Ordinarily the 
calibre of the prostatic urethra is such that it will easily accom- 
modate both these tubes; should such, however, not be the 
case, that through the penile urethra is to be omitted. 

The prostatic urethra is sutured around the perineal tube 
with interrupted stitches of catgut, except where the tube 
emerges, at the triangular ligament (Plate xcn). Three wicks 
of gauze are required to drain the perineal wound, which is par- 
tially closed by a few buried sutures, and by two deep (not buried) 
sutures at each of its angles. A firm gauze pad is placed be- 
tween the coccyx and the anus, so as to hold the rectum forward, 
its normal anterior support having been destroyed by the division 
of the recto-urethral muscle. The usual superficial dressings 
are applied ; and the patient when returned to bed is so arranged 
that the bladder shall be higher than the outer end of the peri- 
neal tube. This is best accomplished by using a perforated 
mattress, and having the tube drain into a urinal beneath the bed. 
If this plan cannot be carried out, Proust advises placing a board 
across the bed beneath the mattress, where the patient's buttocks 
will rest upon it, and thus be effectually prevented from making 
a depression in the bed lower than the outer end of the tube, 
which would then have to drain up-hill. As a substitute for this 
plan, the patient's buttocks may be made to rest upon a firm 
pad or pillow, placed above the mattress. Some such device 
Proust insists is essential to ensure the proper drainage of the 
bladder. The penile catheter is plugged, and all urine passes 
by the perineal tube. 

In the after-treatment, the bowels are kept locked for eight 
days; for the first week the bladder is irrigated twice daily by 
injecting small quantities of fluid through the penile catheter, 



236 Perineal Prostatectomy. 

and allowing it to escape by the perineal tube. The dressing 
is first removed at the end of forty-eight hours, and subsequently 
renewed once every day. He removes the perineal tube on the 
eighth day, and lets the urine then drain by the penile catheter. 
This should be changed frequently to prevent concretions form- 
ing on it; and in doing so the upper wall of the urethra should 
be sedulously followed. Proust employs catheters of the general 
form of Merrier' s, but having an extra eyelet on the convexity 
of the angle; before withdrawing one he passes a straight flexi- 
ble guide along its interior until the guide projects through this 
extra eyelet into the bladder; the catheter is then withdrawn 
over the guide, which remains in the urethra, and serves as a 
conductor for the insertion of the new catheter. 

He prefers to keep the penile catheter in place, changing it 
frequently, for from three to five weeks, that is, until the peri- 
neal wound has closed. Complete healing of the perineal wound 
is generally assured in from five to seven weeks. 

2. Perineal Prostatectomy. Technique of Young. — Young 
[261] calls his method " conservative" perineal prostatectomy, 
its special feature being the preservation of the connection be- 
tween the ejaculatory ducts and the urethra. 

The incision he employs is shaped like an inverted V 
(Plate xciii). At first he used an incision like an inverted Y, 
but he has found that the prolongation of the incision forwards 
on to the bulb of the urethra is not necessary, inasmuch as the 
entire dissection, just as in Proust's technique, is carried on 
posterior to the perineal centre and the transverse perineal 
muscles. Each limb of his A-shaped incision is five centi- 
metres or less in length. 

The position he advises may be characterized as the "exag- 
gerated lithotomy position,' ' the patient's thighs being fully 
flexed on the abdomen, so as to bring the perineum more nearly 
parallel with the floor. 

With a guide in the urethra, the attachments of the anus 



PLATE XCIIi. 







Skin Incisions for Perineal Prostatecto: 



Plate xci-v. 




Young's Prostatic Tractor. 



PLATE XCV 




Fig. i. 




Fig. 



Perineal Prostatectomy. — ( Young.) 
Fig. i. Young's prostatic tractor in place, seen from within the bladder. Fig. 2. Dia- 
gram to show parts removed in operating according to Young's technique : in the centre a 
catheter is seen in the prostatic urethra; below are shown the ejaculatory ducts and uterus 
masculinus in the posterior commissure of the prostate. 



PLATE XCVI. 




Perineal Prostatectomy. — ( Young) 
Incisions on each side of posterior commissure down to the prostatic urethra. The 
prostatic tractor has been introduced through the opening in the membranous urethra, and 
draws the prostate well down into the perineum. 



Technique of Young. 237 

to the perineal centre, and of the rectum to the triangular liga- 
ment, are divided as in the French operation; the "espace decol- 
lable retro prostatique" being thus opened, an incision is made 
into the membranous urethra. The edges of the urethral in- 
cision are caught with silk traction sutures, or suitable clamps, 
and the urethral guide withdrawn. The prostatic tractor (Plate 
xciv) is then inserted into the bladder through the perineal wound ; 
by spreading its blades the prostate can be drawn securely down 
into the perineal wound. An incision is now made with a scalpel 
on each side of the median line, through each lateral lobe of the 
prostate, parallel to and extending as deep as the urethra; leav- 
ing between these two incisions a bridge of prostatic tissue, in- 
cluding the posterior commissure, in which the ejaculatory ducts 
are supposed to lie (Plate xcvi). Each lateral lobe of the pros- 
tate, lying external to the corresponding incision, is then detached 
from its sheath with a blunt dissector and the ringer. When one 
lobe has been freed from its sheath, its connections to the urethra 
and the anterior commissure are severed, and it is removed. 
The second lobe is treated in a similar manner. Thus prac- 
tically all that remains of the prostate is the anterior and pos- 
terior commissures (Plate xcv, Fig. 2). 

A median lobe frequently, when present, is removed at the 
same time as the lateral lobe to which it is attached. If it does 
not come away in this manner, Young says it is easily enucleated 
through the upper end of one of the cavities left by removal of 
a lateral lobe. This is aided by placing one blade of the tractor 
over the vesical aspect of the median lobe. 

At the conclusion of the operation the lateral prostatic cavities 
are to be packed firmly with gauze, additional packing being 
also placed in the retroprostatic space. One limb of the incision 
is closed completely, and through the other, which may be partly 
closed posteriorly, the gauze and rubber drains emerge. He 
employs two perineal tubes, so as to maintain continuous irriga- 



238 Perineal Prostatectomy. 

tion, which he finds necessary to prevent the plugging of the 
tube by clots. 

The continuous irrigation of the bladder through the peri- 
neal wound (Plate xcvii) he continues for a week, the reservoir 
requiring to be filled every half hour with saline solution at a 
temperature of from no° to 120 Fahrenheit. 

As soon as the patient is returned to bed, a subcutaneous 
infusion of salt solution is given. 

The perineal gauze is loosened on the second day, but is not 
completely removed until the sixth day after the operation. The 
tubes are removed at the end of a week, and the patient is allowed 
out of bed. The perineal wound is still kept lightly packed with 
gauze, and on the ninth day, after passing a sound by the urethra, 
a catheter is inserted and fixed in place, constant drainage by 
the penile urethra being maintained for five days more. The 
bladder is irrigated twice daily through this catheter. The 
perineal fistula may be expected to close in five or six weeks. 
Sounds are passed by the urethra only at intervals, not systematic- 
ally. 

3. Partial Perineal Prostatectomy. — The technique about to 
be described is, I think, that still most widely employed in this 
country, and that which is usually intended by the term " peri- 
neal prostatectomy." 

An ordinary staff, or Ferguson's prostatic depressor, being 
in the urethra, the patient is brought into the lithotomy position, 
his legs being supported by assistants. It is undeniable that 
by flexion of the thighs on the abdomen the perineal distance 
is decreased, and this manoeuvre may aid in the removal of the 
offending organ. But I have known femoral thrombosis and 
gangrene of the leg to result from overflexion of the thigh in 
one patient where vaginal hysterectomy was the operation, and 
have since been averse to this exaggerated position for any opera- 
tion upon the perineum. 

A straight median incision is then made from the base of the 



PLATE XCVII. 




Diagram showing the Use of Continuous Irrigation of the Bladder, after 
Young's Operation of Perineal Prostatectomy. 



PLATE XCVII1 





i£ — 







-3 •-' 
- - 



w ~ 

c_ _ 
- — 
= a 
o u 



- o 



M Cfl 



^ 5 



_ be 

- 

bb'S 



PLATE XCIX. 




Syms's Prostatic Tractor en Use. 
Its bulbous extremity has been expanded within the bladder, and by traction on the stem 
the prostate is drawn down into the perineum 



PLATE C. 



Murphy's Hooks, for Use in Perineal Prostatectomy. 



Perineal Prostatectomy. 239 

scrotum to the margin of the anus. This incision lays bare the 
bulb of the urethra anteriorly, and the outer fibres of the anal 
sphincter posteriorly. This incision is deepened by light touches 
of the knife, dividing the perineal centre, and exposing the mem- 
branous urethra. On each side of the wound the fibres of the 
levator ani will be seen descending, those most anterior passing 
in front of the rectum and blending with fibres of the deep trans- 
verse perinei and internal sphincter ani muscles, near the perineal 
centre. 

The membranous urethra should now be opened, and, the 
staff being withdrawn, an ordinary metal sound, or the finger, 
passed through the prostatic urethra into the bladder; by hook- 
ing this over the raised vesical orifice of the urethra the prostate 
may now be drawn down into the wound. If Ferguson's prostatic 
depressor is employed it should not be removed from the urethra, 
but an assistant should, by bearing down on it, push the prostate 
down into the wound. I have no doubt that Young's or Syms's 
tractors are very useful during this part of the operation, but I 
have not found them necessary. 

The anterior fibres of the levator ani are then divided, and 
drawn to each side by hooked retractors, while the rectum and 
its overlying tissues are pressed backwards with a blunt retrac- 
tor. By this means a fairly large operative field is opened up 
in the recto-urethral triangle. It is not the gaping wound of 
Proust, nor even the free exposure of Young, but it is quite 
sufficient for the purpose (partial removal of small fibrous pros- 
tates), and amply large when the time for healing has arrived. 

By now drawing the prostate down into the wound its sheath 
is put upon the stretch, and is readily opened, by two lateral 
incisions, parallel to the urethra. When this has been done, 
the separation of the prostate from its surrounding structures 
should be begun at its posterior part, which is readily reached 
by going along the lateral surfaces of each lobe. One lobe at 
a time is attacked, by drawing it down into the perineum by 



240 Perineal Prostatectomy. 

means of Murphy's hooks (Plates c, evil). This dissection is by 
no means so easy as the shelling out of the gland in the supra- 
pubic operation, for these fibrous prostates are both hard, and 
usually closely attached to the surrounding tissues, so that re- 
moval by morcellement is at times imperative. Especially is 
this the case when the gland is of cartilaginous hardness. Here 
the most that can usually be done is to gnaw away the obstruct- 
ing parts, along with the floor of the prostatic urethra, irrespec- 
tive of lobes, which are often indefinable. 

The floor of the prostatic urethra may well be removed in 
every case, sacrificing thus, of course, the ejaculatory ducts. 
It is generally best to leave behind the upper wall of the ure- 
thra, as well as the anterior commissure of the gland, since their 
removal prolongs the operation and makes it more dangerous, 
and since there is little likelihood of subsequent trouble being 
caused by their presence. In these fibrous prostates it is very 
unusual to find a pedunculated vesical outgrowth, but should 
one be present, it is best removed through the prostatic urethra, 
after dividing its pedicle. 

When as much of the gland as seems advisable has been 
removed, and it is evident that the vesical orifice of the urethra 
is as low as the lowest part of the bladder, a good-sized rubber 
tube is passed into the bladder through the perineal wound, being 
stitched to the skin, and is gently packed around with iodoform 
gauze. If the oozing of blood is persistent, and cannot be con- 
trolled by douching with hot lotions, this packing may be quite 
firmly applied. It should be removed, as a rule, on the third 
or fourth day. A light gauze dressing, held in place by absorbent 
cotton and a T-bandage, completes the operation. 

On being returned to bed the perineal drain is attached by 
glass and rubber tubing to a bottle hanging beside the bed. 
It is well to pay attention to the point so much insisted upon by 
Proust [196],. and to see that the urine has a down-hill course 
from the bladder. 



i 



PLATE CI. 





Skin Incisions for Perineal Prostatectomy. 

The dotted line shows Dittel's incision. The unbroken line shows the incision employed 

in the technique illustrated in Plates Oil to CVIII. 



PLATE CII. 





Perineal Prostatectomy. 
Straight median incision exposing Colles's fascia 



Plate cil 




f 




Perineal Prostatectomy. 
Colles's fascia has been incised, exposing the bulb of the urethra 



PLATE CIV. 




1- 



Perineal Prostatectomy. 
By retracting the margins of the wound the membranous urethra, the transverse 
perineal muscles, and the anterior fibres of the levator ani are exposed, in addition to the 
bulb of the urethra (bulbo-cavernosus muscle) shown in Plate OIL 



PLATE CV. 




Perineal Prostatectomy. 
The membranous urethra is opened on a grooved staff, being more fully exposed by re- 
tracting the rectal tissues downwards. 



PLATE CVI, 




Perineal Prostatectomy. 
By means of Ferguson's prostatic depressor the prostate is pushed well down into 
the perineum, displacing the bulb of the urethra forwards, and the levatores ani muscles to 
either side. The sheath of the prostate has been incised over each lateral lobe, parallel 
to the urethra. 



Plate evil. 




Perineal Prostatectomy. 

„f ^ Ey blU . nt d ! ssection > and with the aid of Murphy's hooks as tractors each lateral lobe 
pt the prostate is removed in turn. The finger or an ordinary sou dm introduced 

enucleation 3 ^ ^^ **"** "* ^^^ de P^ or withdrawn to a[d in the 



PLATE CVIII. 




Perineal Prostatectomy. 
Drainage-tube in place, the wound packed lightly with gauze, and its angles sutured. 



After-treatment. 241 

The outer dressings may be changed once daily, or oftener, 
if required; the packing should be removed about the fourth 
day, and the perineal tube at the end of a week. The bladder 
should be irrigated once daily through the perineal tube. 

Commencing in the second week, a full-sized catheter or 
sound should be passed through the urethra every third or fourth 
day. It will commonly be found that by the end of the second 
week the patient will pass more urine by the urethra than through 
the perineal wound. He should be kept quietly in bed until 
the urine ceases to pass by the perineum, unless his general 
health suffers from the confinement. To encourage the volun- 
tary passage of urine he may turn on his side or even into the 
prone position, early in the second week. The perineal fistula 
may be expected to close in the third or fourth week, and the 
wound to be completely healed at the end of five weeks. 



17 p 



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Trans. Amer. Surg. Assoc, 1903, xxi, 350. 



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171. Morris, R. T.: N. Y. Med. Jour., 1890, ii, 57. 
1 71a. Morton: N. Y. Med. Record, 1904, ii, 561. 

172. Moses: Therapeutische Monatshefte, 1895, ii, 690. 

i720.Motz: Congres International de Medicine, Paris 1900; Section de 
Chirurgie Urinaire, p. 258. Quoted by Guyon [108] vol. i, p. 184. 

173. Moullin, C. W. Mansell: Hunterian Lectures on Enlargement of 

the Prostate, London, 1892. 

174. " " Brit. Med. Jour., 1892, i, 1294. 

175. " " Ibid., 1894, ii, 976. 

176. " " Enlargement of the Prostate. London, 

1899, 2d ed.; 1904, 3d ed. 

177. " " Lancet, Dec. 5, 1903. 

178. Moynihan: Annals of Surgery, 1904, i, 1. 

179. Mudd* see Belfield: Amer. Jour. Med. Sciences, 1890, c, 439. 

180. " St. Louis Med. and Surg. Jour., 1883, x l y > 43&- 

181. Murphy: Jour. Amer. Med. Assoc, March 29, 1902. 

182. " Ibid., 1904, i, 1408, and ii, 14. 



183. Nicoll: Lancet, 1894, i, 926. 



184. Owen: Lectures on the Comparative Anatomy of the Invertebrate 

Animals. London, 1843. 

185. " The Anatomy of Vertebrates. London, 1868, vol. iii, Chap. 

xxxvii, p. 641. 

186. Owens: Trans. Amer. Surg. Assoc, 1902, xx, 79. 



187. Packard: Trans. Amer. Surg. Assoc, 1888, vi, 361. 

188. Paget: Lectures on Surgical Pathology. London, 1870, 3d ed., p. 380. 

189. Parrish: Practical Observations on Strangulated Hernia and some of 

the Diseases of the Urinary Organs. Phila., 1836, p. 253. 

190. Perassi: On Ventrofixation of the Bladder: see Goldman, loc cit. 



250 Bibliography. 

191. Petit: De la Prostatectomie Perineale dans 1' Hypertrophic Simple de 

la Prostate. Paris, 1902. 

192. Pettigrew: On the Muscular Arrangement of the Bladder and Pros- 

tate. London, 1867. 

193. Physick: see Dorsey's Surgery, loc. cit. 

194. Poncet and Delore: Traite de la Cystostomie Sus-Pubienne chez les 

Prostatiques. Paris, 1899. 

195. Pousson: Bull, et Mem. de la Soc. de Chir. de Paris, 1904, xxx, 621. 

196. Proust: Manuel de la Prostatectomie Perineale pour Hypertrophic 

Paris, 1903. 



197. Ramm: Centralbl. f. Chir., 1893, No. 35, S. 759. 

198. Remete: Wiener klin. Rundschau, 1903, xxviii, 3. 

199. Richardson, W. G.: Development and Anatomy of the Prostate 

Gland. London, 1904. 

200. Riolanus, Joannes, filius: Opera Anatomica, Lutetiae Parisiorum, 

1649, f- I 5 I et 1 ^7- 

201. Roberts: Brit. Med. Jour., 1902, i, 769. 
2oi#.Rosenstein: Deutsch. med. Woch., 1904, xxx, No. 36, S. 1309. 

202. Rossetus, Franciscus: 'TZTEPOTO MOTOR IA1 (id est) Csesarei Partus 

Assertio Historologica, Parisiis 1590, Tertia Tractatiuncula, f. 263. 

203. Rydygier: Centralbl. f. Chir., 1902, xxix, No. 41, S. 1057. 



204. Santorini, Jo. Domini cus: Observationes Anatomical, Venetiis 1724. 

Cap. x, Sect, v, f. 181. 

205. " " Ibid., loc. cit., Sect, xix, f. 199, seq. 

206. Schlagintweit : Centralbl. f. d. Krankh. d. Harn-u. Sexualorg., 1901, 

xh, 73- 

207. Schmidt, Benno: quoted by Moullin, Brit. Med. Jour., 1892, i, 1294. 

208. " " Munch, med. Woch., Feb., 1889. 

209. Senn: Jour. Amer. Med. Assoc, 1903, ii, 414. 

210. " Practical Surgery, Philadelphia, 1902. 

211. Simpson, Sir J. Y.: Anaesthesia, Hospitalism, etc. N. Y., 1872, p. 509. 

212. Socin and Burckhardt: Die Verletzungen und Krankheiten der Pro- 

stata, Stuttgart, 1902. 

213. Spanton: Lancet, 1882, i, 1032. 

214. Ssnitzin: Lyon Med., 1894, Tom. 76, p. 132; also Deriuschinski: Cen- 

tralbl. f. Chirurg., 1896, xxiii, 898; cf. Centralbl. f. d. Krankh. d. 



Bibliography. 251 

Harn-u. Sexualorg., 1897, viii, 693; see also Derujinsky: Annales des 
Malad. des Org. Genito-urin., 1897, xv, 848. 

215. Steinach: see American Textbook of Physiology, 1896, p. 885. 

216. Stern: Amer. Jour. Med. Sciences, 1903, cxxvi, 277. 

217. Stoker: Brit. Med. Jour., 1904, i, 229. 

218. Stricker: Human and Comparative Histology. Translation of New 

Sydenham Soc, London, 1872, vol. ii, p. 300. 

219. Syms: N. Y. Med. Record, 1901, ii, 35. 

220. " Annals of Surgery, 1902, i, 468. 

221. " Jour. American Med. Assoc, 1904, ii, 1378. 

222. Taylor: Brit. Med Jour., 1902, i, 774. 

223. Tenney: quoted by Watson, Annals of Surgery, 1904, i, 834. 

224. Thompson, Sir Henry: Diseases of the Prostate. London, 1858. 

225. " " Lancet, 1875, h 3- 

226. Thorel: Beitrage z. klin. Chirurg., 1902, xxxvi, 630. 

227. Thorndike: Bost. Med. and Surg. Jour., 1902, vol. 147, p. 233. 

228. Tobin: Med. Press and Circular, London, 1890, ii, 571. 

229. " Brit. Med. Jour., 1902, i, 774. 

230. Trendelenburg: quoted by Moullin, Brit. Med. Jour., 1894, ii, 976. 

231. Tupper: see Walker, N. Y. Med. Jour., April, 1895. 



232. Velpeau: Treatise on the Diseases of the Breast. Translation of the 

Sydenham Soc, London, 1856, p. 287. 

233. Yerhoogen: Centralbl. f. Chir., 1902, No. 50, S. 1296. 

234. Vignard: see Guyon, loc cit., vol. i, p. 198. 

235. Walker, George: Johns Hopkins Hosp. Bulletin, 1900, xi, 242. 

236. Walker, J. W. T.: Practitioner, London, 1904, vol. 73, p. 239. 

237. " " Brit. Med. Jour., 1904, i, 728. 

238. " " Ibid., loc. cit., ii, 62. 

239. Wallace: Brit. Med. Jour., 1902, i, 764. 

240. " Ibid., Jan. 30 and May 21, 1904, p. 1187. 

241. W t anless: Indian Med. Gazette, 1904, xxxix, 45, 82. 

242. Watson, F. S.: The Operative Treatment of the Hypertrophied Pros- 

tate. Boston, 1888. 

243. " " Annals of Surgery, 1889, ix, 1. 

244. " " Ibid., 1904, i, 833. 



252 Bibliography. 

245. Watson, F. S.: Bost. Med. and Surg. Jour., 1895, ii, 154. 

246. " " Ibid., 1904, i, 453. 

247. White, J. Wm.: Trans. Amer. Surg. Assoc, 1893, xi, 167. 

248. " " Ibid., 1895, xii, 130. 

248a. " Annals of Surgery, Dec, 1904. 

249. Whitehead: Brit. Med. Jour., 1889, i, 831. 

250. Wiener: Jour. Amer. Med. Assoc, 1904, i, 1278. 

251. Wiesinger: quoted by Poncet and Delore, loc cit., p. 203. 

252. Wishard: N. Y. Med. Jour., Aug. 17, 1901. 

253. " Jour. Cut. and Gen.-Urin. Dis., 1902, xx, 245. 

254. Wistar: see Parrish, loc cit. 

255. Wolf, Moreau-: see Cheron and Moreau-Wolf. 

256. W t olef: Deutsche med. Woch., 1899, quoted by Socin and Burckhardt, 

loc. cit. 

257. Wood, A. C: Annals of Surgery, 1900, xxxii, 309. 

258. Woolsey: Jour. Cut. and Gen.-Urin. Dis,, 1895, xiii, 229. 

259. Wossidlo: Centralbl. f. d. Krankh. d. Harn-u. Sexualorg., 1900, xi, 113. 



260. Young, H. H.: Jour. Amer. Med. Assoc, Jan. 11, 1902, i. 

261. " Ibid., 1903, ii, 999. 

262. " Ibid., 1905, i, 337. 



263. Zuckerkandl: Wien. med. Presse, 1889, xxx, 857, 902. 



INDEX OF NAMES. 



Adams, 18, 42 
Albarran, 14, 15, 208, 213 
Albarran and Halle, 65, 66, 116 
Alexander, 15, 49 
Annandale, 14 
Armstrong, 211 
Ashhurst, 14, 96, 205 
Astruc, 3 
Atkinson, 11 



Bangs, 6, 179 
Barling, 14, 208 
Baudet, 14 
Bazy, 153 

Belfield, 6, 11, 120, 211 
Bier, 17 

Billroth, 3, 14, 46 
Blizzard, 4, 5 
Boeckmann, 16 
Bottini, 6, 188 
Bouffleur, 6, 182 
Braun, 10 
Brodie, 2 

Brooks, 65, 66, 69, 70, 90 
Brown, Buckstone, 11 
Bryson, 14, 15 

Buckstone Brown (see Brown). 
Burckhardt, 18, 123, 135, 178, 179, 
184, 185, 194, 195, 196, 205, 210 



Cabot, 79, 100, 159, 163, 196 

Cheron and Moreau-Wolf, 10 

Chetwood, 116 

Chismore, 161 

Chopart, 2, 3, 4 

Ciechanowski, 28, 47, 62, 65, 68, 89, 90 

Civiale, 5, 13 

Conner, 84 

Coulson, 18 

Covillard, 4 

Crandon, 65, 68, 90 

Cuneo and Veau, 25 

Czerny, 178, 182 



Daniel, 65, 67 
Deaver, 208 



Delore, 9, 18, 169 
Demarquay, 14 
Denonvilliers, 31 
Derjuschinsky, 18, 196 
Desault, 4, 47 

Dittel, 9, 10, 11, 14, 15, 86, 157 
Dodeuil, 49 
Dorsey, 7 



Edebohls, 163 
Edwards, Swinford, 9 
Englisch, 196 
d'Etiolles, Leroy (see Leroy). 



Fen wick, 32, 33 

Ferguson, 14, 208 

Fergusson, Sir Wm., 5 

Finney, 179 

Freudenberg, 6, 178, 179, 182, 183, 185, 

186, 189 
Freyer, 11, 13, 14, 18, 41, 57, 64, 135, 144, 

201, 203, 205, 208, 211 
v. Frisch, 182, 183, 185 
Fuller, 11, 16, 211 
Furbringer, 42 



Galen, 2 

Gant, 18 

Goldman, 53 

Goodfellow, 14, 206, 208, 213, 219, 231 

Gouley, 4, 5, 6, 10, 13 

Greene and Brooks, 65, 66, 69, 70, 90 

Griffiths, 17, 22, 24, 27, 34, 49 

Guiteras, 16 

Guthrie, 5, 22 

Guyon, 17, 18, 46, 53, 130, 142 



Halle, 65, 66, 116 

Haller, 42 

Harrison, R., 4, 10, 13, 14, 18, 45, 47, 53, 

76, 88, 118, 140, 163, 205 
Heine, 10 
Henle, 43 
Herophilus, 2 
Herring, 65 



253 



254 



Index of Names. 



Hey, 7 

Hodernus, Bjorn, 169 

Hodgson, 18, 21, 34, 46, 88, 90 

Home, 1, 2, 18, 23, 24, 47 

Horwitz, O., 6, 169, 179, 208, 211 

Humphrey, 86 

Hunter, John, 2, 17, 23, 27, 42 



Iversen, 10 



Keyes, 11, 72, 161, 178, 180 
Keyes, Jr., 6 
KSnig, 18, 178, 182 
Krynski, 53 
Kiichler, 14 
Klimmel, 1 1 



Laeaye, 3 

Lagoutte, 169 

Langenbeck, 10, 14 

Launois, 17 

Leisrink, 14 

Leroy d'Etiolles, 3, 5, 13, 18, 130 

Leuckhart, 21 

Loumeau, 28, 208 

Lydston, 87, 88, 118 



Macewen, 89 

MacGowan, 209, 211 

Mansell Moullin (see Moullin). 

Massa, Nicolo, 2 

McGill, 11, 86, 202, 207 

McGuire, H., 9, 86, 167, 169, 171, 172, 173 

McRae, 208 

Mears, 17 

Merrier, 3, 5, 6, 13, 47 

Meyer, Willy, 6, 17, 161, 170, 179, 182, 

183, 185 
Moore, J. E., 14, 202 
Moreau-Wolf, 10 
Morgagni, 23, 42 
Morris, H., 14 
Morris, R. T., 9 
Morton, 209 
Moses, 89, 198 
Motz, 65 
Moullin, 17, 18, 25, 27, 44, 49, 64, 76, 86, 

93> . I2 5> !3 2 > 134, i9 6 > J 97> 211, 213 
Moynihan, 14, 208 
Mudd, 86 
Murphy, 14, 16, 209 



Nicoll, 15 



Owen, 25, 27 

Paget, Sir J., 46, 94 
Paget, Thomas, 8 
Parrish, 8 
Perassi, 53 
Petit, 14, 18 
Pettigrew, 35 
Physick, 3, 7 
Pisani, 178 

Poncet and Delore, 9, 18, 169 
Proust, 14, 15, 16, 18, 38, 207, 213, 218, 
230, 232, 240 

Ramm, 16 

Remete, 89 

Richardson, W. G., 22, 26, 207, 227 

Riolanus, 2, 13 

Roberts, 13 

Rosenstein, 190 

Rossetus, 7 

Roth, 178 

Rouchaud, 18 

Rydygier, 182 

Santorini, 31, 39 

Schafer, 27 

Schlagintweit, 190 

Schmidt, Benno, 11 

Schultz, 84 

Senn, 14, 135, 141, 202 

Simpson, Sir J. Y., 21 

Socin, 154 

Socin and Burckhardt, 18, 123 

Spanton, 14 

Ssnitzin, 17 

Steinach, 42 

Stern, 43 

Stockmann, 185 

Stoker, 208 

Strieker, 25 

Syms, 14, 16, 209, 213 

Taylor, 12 

Thompson, Sir H., 4, 8, 9, 18, 24, 46, 86 

Thorel, 24 

Thorndike, 211 

Tobin, 11, 87, 198 

Trendelenburg, 11 

Tupper, 16 

Veau, 25 
Velpeau, 46, 53 
Verhoogen, 178, 209 
Vignard, 18, 75 
Virchow, 21 



Index of Names. 



255 



Walker, Geo., 36, 68 

Walker, J. W. T., 13, 225 

Wallace, 12, 35 

Wanless, 85, 87, 208 

Watson, 6, 11, 14, 18, 152, 163, 169, 178, 

179, 184, 202, 210, 212 
White, J. Wm, 16, 87, 196 
Whitehead, 10 
Wiener, 208, 219 
Wiesinger, 169 
Wishard, 6, 85 
Wistar, 8 



Wolf, Moreau-, 10 
Wolff, 133, 135 
Wood, A. C, 17, 196 
Wossidlo, 185, 190 



Young, H. H., 6, 14, 15, 16, 42, 161, 179, 
181, 182, 183, 190, 194, 207, 209, 213, 
230, 236 



ZUCKERKANDL, I 4 



INDEX. 



Abscess, prostatic, 67 

differential diagnosis of, 116 
Accessory lobe, 24 

prostates, 24, 62 

pudic artery, 33 
Acini, prostatic, 34 

histology of, 36 
Acute complete retention of urine, 142 
Etiology, 46 
After-treatment, Bottini operation, 194 

perineal prostatectomy, 235, 237, 241 

suprapubic prostatectomy, 228 
Age as a cause, 85 
Air-distention of bladder, 170 

in Bottini operation, 190 
Alexander's operation, 15 
Alkaline urine, 80 
Allantois, 20 

Ammoniacal decomposition of urine, 80 
Ampullae of vasa deferentia, 41 
Anaesthetic, 218 
Anal fascia, 31 
Anatomy, 20 

applied, 37 

comparative, 25 

gross, 28 

microscopical, 34 

surgical, 37 
Anorexia as symptom, 98, 106 
Anus, prolapse of, causes of, 82 

as symptom, 98 
Aponeurosis of Denonvilliers, 24, 25, 31, 38 
Appetite, loss of, 98, 106 
Applied anatomy of prostate, 37 
Arteries, ligation of internal iliac, 1 7 

of prostate, 33 
Arteriosclerosis as cause, 91 
Artery, accessory pudic, 33 

vesico-prostatic, ^^ 
Artificial urethra, 9 

Aspiration of bladder for acute retention, 157 
for retention with overflow, 160 
Atony of bladder, 78 

differential diagnosis of, 113 
prevention of, 143 
treatment of, 157, 159 
Atrophy of prostate, differential diagnosis 

of, 116 
Axis of prostate, 30 
18 



Bacillus coli communis in urine, 80 
Backward pressure on kidneys, 79 
Bacteria in cystitis, 81 
Bar at neck of bladder, 5, 77 
Batrachians, prostate in, 25 
Bibliography, 243 
Bi-coude catheters, 130 
Bier's operation, 17 
Birds, prostate absent in, 25 
Bladder, aspiration of, 157, 160 
atony of, 78 

differential diagnosis of, 113 
prevention of, 143 
treatment of, 157, 159 
bar at neck of, 5, 77 
changes in, 76 

continuous irrigation of, after prosta- 
tectomy, 238 
contracted, 78 
dilatation of, 78 
dilation of, for cystitis, 150 
distended, as symptom, 100 
distention of, with air, 170, 190 
drainage of, for cystitis, 151 
for surgical kidneys, 163 
examination of, with catheter, 103 
external sphincter of, 44 
gradual distention of for cystitis, 150 
haemorrhage into, prevention of, 145 

treatment of, 161 
in cystitis, 78 
infected, 78 
irrigation of, 148 

continuous, after prostatectomy, 
238 
ligaments of, 38 
macroscopical changes in, 77, 78 
microscopical changes in, 65 
paralysis of, differential diagnosis of, 

114 
polypi of, differential diagnosis of, 115 
pouches of, 78 
puncture of, 7, 157, 160 
sclerosis of neck of, 116 
stone in, as symptom, 98 

differential diagnosis of, 114 
urethral orifice, shape of, 76 
Bleeding in suprapubic prostatectomy, 225 
Blood, examination of, 107 



257 



2 5 8 



Index. 



Blood in bladder, 81 

in urine, as symptom, 97 

Bottini apparatus, description of, 188 
operation, 176 

accidents of, 181, 210 
advantages of, 185 
after-treatment, 194 
causes of death after, 210 
dangers in after-treatment, 183 
history of, 6 
incisions in prostate, 194 
indications and contraindications, 

186, 187 
limitations of, 182 
mortality of, 178 
objections to, 179 
results of, 184, 210 
special requirements of, 179 
statistics of, 178, 179, 210 
technique of, 191 
through perineal wound, 6 
through suprapubic wound, 6 
uncertainties of, 181 

Bougies, Harrison's olivary, 4 

Bryson's operation, 15 

Bursa, recto-prostatic, 24 

Calcareous deposits in bladder, 80 
Calculus, vesical, differential diagnosis of, 
114 
frequency of, with enlarged pros- 
tate, 114 
prevention of, 144 
symptom of enlarged prostate, 98 
treatment of, 161 
Capsule of prostate, 29, 35 
Caput gallinaginis, 29, 37 
Carcinoma of prostate, differential diag- 
nosis of, 116 
Carcinomatous changes in prostate, 66 
Cardiac dilatation, 107 
hypertrophy, 106 
symptoms, 98 
Carnosities at neck of bladder, 1 
Castration, 195 

before puberty, 88 

effects of, on prostate, 88, 89 

due to physiological rest, 89 
for persistent sexual desires, 87 
history of, 16 
in dogs, 28 
mania after, 197 
Casts in urine, 106 
Catheterism, 128 

expectation of life in, 1 18 
Catheterization, continuous, 7, 151 
forced, 3 

frequency of, 139 
in overflow from retention, 100 



Catheters, 128 

bi-coude, 130 

care of, 132 

by patient, 134 

cases for carrying, 135 

choice of, 135 

coude, 7, 130 

double-elbowed, 130 

elbowed, 7, 130 

English, 129 

in-lying, 151 

intravesical examination with, 103 

Leroy's, 130 

lubricant for, 135 

Mercier's, 130 

metallic, 131 

method of passing, 135 

Nelaton's, 129 

permanent drainage by, 151 

prostatic, 131 

silver, 131 

soft rubber, 129 

sterilization of, 132 

varieties of, 128 

webbed, 129 
Causes, 46 

adenomyomatous changes, 46, 49 

age, 85 

arteriosclerosis, general, 46, 49, 91 

clinical, 84 

compensatory hypertrophy, 46, 49 

gonorrhoea, 90 

habits, 87 

high living, 87 

inflammation, 49, 65, 90 

nationality, 84 

occupation, 86 

previous diseases, 90 

race, 84 

sexual intercourse, 87 

strictures of urethra, 90 
Cervix uteri enlargement of prostate, 76, 

77 
China, enlargement of prostate in, 85 
Chloroform preferred to ether, 219 
Clinical causes, 84 

pathology, 72 

stages of enlargement of prostate, 98 
Cock's operation for retention with over- 
flow with strictures, 161 
Coitus, painful, as symptom, 98 
Colon bacillus in urine, 80 
Coma as symptom of uraemia, 98 
Combined examination by bladder and 
rectum, 103, 104 

operations, 15 
Commissures, prostatic, 34 
Comparative anatomy, 25 

pathology, 28 



Index. 



259 



Compensatory hypertrophy, 45 
Complications, prevention of, 140 

treatment of, 147 
Compression of prostate, systematic, 3, 140 
Concretions, prostatic, 43, 68 
Conservatism in operating, 204 
Conservative perineal prostatectomy, 236 
Constipation as symptom, 98 
Constitutional treatment, 121 
Constrictor urethrae, 40, 44 
Contents, table of, ix 
Continuous catheterization, 7, 151 
Convulsions as symptom of uraemia, 98 
Cord, genital, 22 
Coude catheter, 7, 130 
Cryptorchidism, 88 
Curve of catheter, 131 

increased by partially withdraw- 
ing stylet, 7, 138 
Cystic prostate, 6j 

clinical history, 56 
Plates XXXV, XXXVI, XL VII 
Cystitis, cystotomy for, 153 

differential diagnosis of, 114 

drainage of bladder for, 151 

pathology of, 78 

prevention of, 140 

symptom of enlarged prostate, 96 

treatment of, 147 

urine in, 80 
Cystoscope in diagnosis, no 
Cystotomy for acute retention, 157 

for cystitis, 153 

for retention with overflow, 160 

history of, 7 



Death, causes of, after operation, 210 
Defalcation in enlarged prostate, 82 
Denonvilliers, aponeurosis of, 24, 25, 31, 38 
DePezzer's prostatic tractor, 233 
Depressor, Ferguson's prostatic, 238 
Descent of vesical floor, 76 
Diagnosis, 108 

catheterization in, 10 1 

cystoscopic, no 

differential, 112 

of fibrous prostate, 112 

of glandular prostate, in 

principles of, 108 
Dietetic treatment, 124 
Differential diagnosis, 112 

in presence of urethral strictures, 

113 
of abscess of prostate, 116 
of atony of bladder, 113 
of atrophy of prostate, 116 
of calculus, vesical, 114 
of cystitis, 114 



Differential diagnosis of malignant disease 
of prostate, 116 
of paralysis of bladder, 114 
of polypi of bladder, 115 
of prostatic abscess, 116 
of prostatitis, 115 
of sclerosis of neck of bladder, 

116 
of tuberculosis of bladder, 115 
Digital divulsion of prostate, 10, 175 
Diseases, previous, as cause, 90 
Distended bladder as symptom, 100 
Distention of bladder in Bottini operation, 

190 
Dittel's incision, 15 
Plate CI 
operation, 15 
Division of bar at neck of bladder, 5 
Divulsion of prostate, digital, 10, 175 
Dog, castration in, 28 

prostatic enlargement in, 28, 198 
urethritis in, 28 
Dorsal vein of penis, 32, 38 

Plate XII 
Double-elbowed catheters, 130 
Drainage after suprapubic prostatectomy, 
226 
Plate LXXXIII 
of bladder for cystitis, 151 
for surgical kidneys, 163 
Dropsy as symptom, 98 
Drugs in treatment, 125 
Duck -mole, 27 
Ducts, prostatic, 29 

histology of, 35 _ 

Dyspnoea from cardiac failure, 106 

symptom of uraemia, 97 

ECCLESIASTES, Book of, I 

Edebohls's operation, 163 
Effects on bladder, 76 

on kidneys, 79 

on rectum, 82 

on ureters, 79 

on urethra, 72 

on urination, 81 
Ejaculatory ducts, 29, 41 
ligation of, 234 
preservation of, 214 
Elastic compression of prostate, 3 

tissue in prostate, 36 
Elbowed catheter, 7, 130 
Electricity, 10 
Embryology, 20 
Enemata, 126 

Ergotine, subcutaneous use of, 10 
Espace decollable retroprostatique, 38 
Ether, chloroform preferred to, 218 



260 



Index. 



Examination, combined intravesical and 
rectal, 103 
Plate LIX 
physical, 100 
general, 105 
Excrescences at neck of bladder, 1 



Fascia, anal, 31 
obturator, 30 
pelvic, 30 
rectovesical, 31 

Plates XIII. 
transversalis, 30 
Female, prostate in, 21 
Ferguson's prostatic depressor, 238 

Plate XCVIII 
Fever, urinary, prevention of, 141 
Fibroblasts, 68 
Fibrous overgrowth, 49 
causes of, 69 
prostate, clinical history of, 50, 54, 55 
diagnosis of, 112 
Plates XXXI, XXXIII, XXXIV 
Fishes, prostate in, 25 
Fistula, urachal, 9 

urinary, history of, 8, 9 
treatment by, 166 
Flatulency, 106 
Foetus, prostate in, 22 

Plate VII 
Food in treatment, 124 
Forced catheterization, 3 
Frequency of enlargement of prostate, 86 
Freudenberg's instruments, 6, 190 

Plate LXXII 
Freyer's and McGill's operations com- 
pared, 212 
Freyer's operation, failure of, 201 
history of, 11 
statistics of, 208 
Fuller's operation, 16 
Function of prostate, 42 



Galvanocaustic prostatotomy, 6, 176 
Genital cord, 22 
"Glandulae prostatas, " 23 
Glandular overgrowth, 49 

causes of, 69 
prostate, clinical history of, 48 

diagnosis of, 11 1 

Plates XXIX, XXX 
tissue of prostate, histology of, 34 
Goat, genitalia of, 26 

Plate IX 
Gonorrhoea as cause, 90 
Goodfellow's operation, technique of, 231 
Gout as cause, 87 



Gross anatomy of prostate, 28 
Growth, rate of, 63 
Guiteras's operation, 16 



Habits as cause, 87 

Habits, regulation of, in treatment, 121, 

122 
Hematuria, symptom, 97 
Haemoglobin, amount of, 107 
Haemorrhage in suprapubic prostatectomy, 
225 
into bladder, prevention of, 145 

treatment of, 161 
secondary, 229 

after Bottini operation, 183 
Haemorrhoids, causes of, 82 
Haemostasis after suprapubic prostatec- 
tomy, 226 
Plate LXXXII 
Harrison's bougies, 4 
Plate II 
operation, 10 
Heart, disease of, 107 
Heart-failure, symptom, 98 
Hedgehogs, prostate in, 27 
Henle's muscle, 43, 44 
Hiccough, symptom, 97 
High living, cause, 87 
Histology of prostate, 34 

enlarged, 65 
History, 1 
Hooks, Murphy's, 240 

Plates C, CVII 
Hyena, genitalia of, 27 

Plate X 
Hygienic treatment, 121 
Hypertrophy, compensatory, of prostate, 45 
Hypogastric tumor, 100 



Incision of neck of bladder, 2 

for suprapubic prostatectomy, 219 
Plate LXXVI 
Incisions in Bottini operation, 194 

Plates LXXIII, LXXIV, 
LXXV 
in perineal prostatectomy, 14 

Plates LXXXV, XCIII, CI 
Incisionskystoskop, 190 
Incontinence of urine, symptom, 95 
India, enlargement of prostate in, 84 
Indications for radical treatment, 200 
Inflammation, cause, 65 
previous, cause, 90 
Injections of iodine, 10 
Insects, prostate in, 25 
Intermittent urination, symptom, 94 



Index. 



261 



Internal iliac arteries, ligation of, 17 
pudic artery, abnormality of, 33 
Intravesical examination with catheter, 103 
Iodine, parenchymatous injections of, 10 
Irrigation of bladder, 148 
continuous, 238 
Plate XCVII 



Japan, enlargement of prostate in, 85 



Kidneys, disease of, as a symptom, 97 
effects of enlargement of prostate on, 

examination for disease of, 106 
surgical, 80 

prevention of, 146 

treatment of, 162 



Laxatives, 126 

Length of urethra in enlargement of pros- 
tate, 72 
Leroy's catheter, 130 
Levator ani, 30, 31, 39 

Plates XIII, XVI, XVIII, XXI, 
XXVII 
prostatas, 31, 39 
Ligaments, puboprostatic, 31, 38 

Plate XV 
Ligation of iliac arteries, 1 7 
Lip-formation at vesical orifice of urethra, 

62 
Literature, 1, 18 
Litholapaxy for calculus with enlargement 

of prostate, 161 
Lithotomy and prostatectomy, combined, 
mortality of, 210 
for calculus with enlargement of 
prostate, 161 
Lobe, accessory, 24 

ducts of median, 30 
"median," 23 

enlargement of, 61, 62 
removal of, 205 
Lobes of prostate, 30 
Loss of sexual power, symptom, 98 
Lubricant for catheters, 35 
Lymphatics of prostate, 34 
Lymph-nodes of prostate, 36 
Walker's, 68 



Malignant changes in prostate, 66 

disease of prostate, differential diagno- 
sis of, 116 
Mammals, prostate in, 25 
Mania after castration, 197 



McGill's operation, 11 

statistics of, 211 
compared with Freyer's, 212 
McGuire's obturator, 173 
Plate LXVI 
operation, 9, 169 
statistics of, 169 
Meatotomy, 137 
Median lobe, 23 

ducts of, 30 
enlargement of, 57 

Plates, I, XLIII, XLIV, LII 
removal of, 205 
Mercier's catheter, 7, 130 
Plate LXI 
operation, 5 

prostatectome and prostatotome, 5 
Plate III 
Metallic catheters, 131 

Plate LXI 
Microscopical anatomy, 34 
Middle lobe (see Median). 
Moles, prostate in, 27 
Morcellement, prostatectomy by, 202, 240 
Mortality of Bottini operation, 178 
of McGuire's operation, 169 
of prostatectomy, 208 
Mullerian ducts, 20 
Murphy's hooks, 16, 240 

Plates C, CVII 
Muscular tissue of prostate, 34 



Neck of bladder, bar at, 5, 77 
Plate LV 
elevation of, 76 
Plate L 
Negroes, enlargement of prostate in, 
Nephritis, prevention of, 146 
treatment of, 162 
urine in, 81 
Nerves of prostate, 33 
Ni coil's operation, 15 
Nocturnal frequency of urination, 93 



Objective symptoms, 100 
Obstipation as symptom, 98 
Obturator fascia, 30 

for suprapubic fistula, 173 
Plate LXVI 
Occupation as cause, 86 
(Edema of extremities, 106 

of prostate, 77 
Old age, its influence on enlargement of 

prostate, 86 
Olivary bougies, 4 

Plate II 
Operation, accidents of, 210 



262 



Index. 



Operation, Alexander's, 15 

Bangs's, 6 

Bier's, 17 

Bottini's, 6, 176 

Bouffleur's, 6 

Bryson's, 15 

choice of, 200 

combined, 15 

Edebohls's, 163 

Freyer's, 11, 219 

Fuller's, 16 

Guiteras's, 16 

Harrison's, 10 

Keyes's, 6 

McGilFs, 11 

Mercier's, 5 

Nicoll's, 15 

Thompson's, 8 

Watson's, 6 

Wishard's, 6 
Operations, technique of, 215 
Orchidectomy, 196 

unilateral, 197 
Orchitis, prevention of, 146 

treatment of, 161 
Ornithorhyncus, 27 

Overflow from retention, catheterization in, 
100 
symptom, 95 
treatment of, 159 
Overstrain, prostatic, 87 
Owens's perineal tube, 176 
Plate LXX 



Paralysis of bladder, differential diag- 
nosis of, 114 
Parenchymatous injections of iodine, 10 
Partial perineal prostatectomy, 238 
Pathological histology, changes in glandular 
tissue, 66 
in stroma, 68 
Pathology, 46 
clinical, 72 
comparative, 28 
density of prostate, 63 
duration of symptoms in fibrous and 

glandular varieties, 49, 50 
fibrous enlargement, 49 
glandular enlargement, 49 
histology, 65 

inflammation as cause, 65 
microscopy, 65 

physical characters of enlarged pros- 
tate, 62 
round-celled infiltration, 68 
size and direction of growth, 53 
suppuration of prostate, 67 
theories as to cause, 53 



Pathology, weight, 53, 57 
Pelvic fascia, 30 

Penis, amputation of, its effect on prostate, 
90 
dorsal vein of, 32, 38 
Perineal fistula, history, 9 
treatment by, 174 
operations, history, 4 
prostatectomy, conservative, 236 
history, 14 
in dogs, 28 
statistics of, 208 
prostatotomy, 4, 5, 174 
puncture, 7 
Plate V 
section for retention with overflow 

and impassable strictures, 160 
tubes, 176 

Plate LXX 
Perineum, anatomy of, 39, 40 

Plates XXIII, XXIV, XXV, 
XXVI, XXVII, XXVIII 
Peritoneum, relations of, to bladder, 41 

Plate XXII 
Phleboliths in prostatic plexus, 32, 82 
Physical examination, 100 
Physiology, 42 

Piles in enlargement of prostate, 82 
Plates, description of the, xi 
Polypi of bladder, differential diagnosis of, 

US 
Postprostatic pouch, 76 

Plate L 
Pouches of bladder, 78 
Preface, vii 

Preparation of patient for operation, 215 
Pressure, backward, on kidneys, 79 
Previous diseases as cause, 90 
Priapism, symptom, 98 
Prognosis, 117 

expectation of life in catheterism, 118 
mortality of various forms of treat- 
ment, 118, 119 
Prolapsus ani, causes of, 82 

symptom, 98 
Prostate, abscess of, differential diagnosis 
of, 116 
accessory, 24 
acini of, 34 

histology of, 36 
arteries of, ^^ 
at birth, 23 
at puberty, 43 

atrophy of, after castration, 197 
differential diagnosis of, 116 
axis of, 30 
capsule of, 29, 35 
cervix uteri enlargement of, 76, 77 
commissures of, 34 



Index. 



263 



Prostate, compensatory hypertrophy of, 45 
digital divulsion of, 10, 175 
ducts of, 29 

histology of, 36 
elastic tissue in, 36 
enlarged, abscesses in, 67 

clinical stages in, 98 

cystic, 67 

clinical history, 56 
Plates XXXV, XXXVI, 
XLVII 

diagnosis of fibrous and glandular 
forms, in 

frequency of, 86 

growth, direction of, 57 
rate of, 63 

in dog, 198 

intravesical portion, 64 

lip-formation, 62 

malignant changes in, 66 

"median lobe" of, 57 

physical characters, 62 

prostatic "tumors," 63 

size of, 53 

stages of, 51 

suppuration of, 67 

urethra in, 72, 74 

varieties of, 49 

weight of, 53 
first use of term, 2 
function of, 42 
in birds, absent, 25 
in female, 21 
in foetus, 22 
in monkey, 2 
in old age, 44 
in sexual excitement, 43 
in urination, 44 
lobes of, 30 
lymphatics of, 34 
lymph-nodes in, ^6, 68 
nerves of, ^^ 
oedema of, 77 
plexus of, 32 
relation of testicles to, 88 
shape of, 28 
sheath of, 29, 30 
sinuses of, 29 
size of, 28 
stroma of, 29 
structure of, 28 
veins of, 32 
weight of, 28 
Prostatectome, 5 
Prostatectomy in dogs, 28 

partial, indications for, 204 
perineal, accidents of, 210 

after-treatment of, 235, 237, 241 

causes of death after, 210 



Prostatectomy, perineal, history of, 14 
partial, 238 
results of, 210 
statistics of, 208 
technique of, 230 
suprapubic, accidents of, 210 
advantages of, 206 
after-treatment of, 228 
causes of death after, 210 
history of, 11 
partial, 204 
results of, 210 
statistics of, 208, 211 
strictures after Freyer's operation 

of, 229 
technique of, 219 
Prostatic atrophy, differential diagnosis of, 
116 
concretions, 43 

in pathological histology, 67 
depressor, Ferguson's, Plate XCVIII 
fluid, 42 
overstrain, 87 
plexus, 32 

tractor, DePezzer's, 16, 233 
Syms's, 16, 239 

Plates, XCVIII, XCIX 
Young's, 16, 237 

Plates XCIV, XCV, XCVI 
tumors, 63, 67 
urethra, anatomy of, 29 

histology of, 36 
utricle (See Uterus masculinus). 
Prostatitis, differential diagnosis of, 115 
Prostatotome, 5 

Prostatotomy, galvanocaustic, 6, 176 
perineal, 4, 5 

technique of, 174 
urethral, 5 
Proust's operation, technique of, 232 
Puberty, castration, before, 88 

prostate at, 43 
Pubo-prostatic ligaments, 31, 38 

muscles, 39 
Puncture of bladder, 7, 157, 160 
Purges, 126 
Pyelitis, 80 

Race as a cause, 84 
Radical treatment, indications for, 200 
Rectal puncture, 7 

Recto-prostatic aponeurosis (See Aponeu- 
rosis o) Denonvilliers). 
Recto-urethral muscle, 40, 233 
Recto-vesical fascia, 31 
Rectum, effects on, 82 
Renal complications, prevention of, 146 
treatment of, 162 
failure, symptom, 97 



264 



Index. 



Resection of floor of urethra, 234, 240 
Residual urine, 76, 80 

amount of, 101, 103 

prevention of, 143 

treatment of, 158 
Results of operation, 210 
Retention of urine after Bottini operation, 

183 
catheterization in, 100 
causes of, 81, 82 
prevention of, 141 
symptom of enlarged prostate, 95 
treatment of, 154 
varieties of, 141 

acute complete, 142 

treatment of, 154 
chronic complete, 143 

treatment of, 157 
incomplete, 143 
with overflow, prevention of, 143 
treatment of, 159 
Retzius, space of, 31 

urinary extravasation into, 221 
Round-celled infiltration of prostate, 68 



Santorini, plexus of, 32 

Sarcoma of prostate, differential diagnosis 

of, 116 
Sclerosis of neck of bladder, 116 
Secondary haemorrhage after Bottini oper- 
ation, 183 
after prostatectomy, 229 
Senn's sigmoid catheter, 173 

Plates LXVII, LXIX 
Sexual excitement, prostate during, 43 

intercourse, overindulgence in, as 

cause, 87 
power, loss of, as symptom, 98 
Shape of normal prostate, 28 
Sheath of prostate, 29, 30 
Shoes, incrustation of, 94 
Silver catheters, 131 
Sinus, prostatic, 29 

urogenital, 21 
Size of normal prostate, 28 
Somnolence as symptom of uraemia, 98 
Sphincter ani, 39, 40 
Stages, clinical, of enlargement of prostate, 

98 
Stammering in micturition, 81 
Statistics of Bottini's operation, 178, 179, 
210 
of Freyer's operation, 208 
of McGilPs operation, 211 
of perineal prostatectomy, 208 
Stevenson's tube, for suprapubic fistula, 

173 
Plates LXVI, LXVIII 



Stone in bladder, prevention of, 144 

symptom of enlarged prostate, 98 
treatment of, 161 
Strictures of urethra after suprapubic 
prostatectomy, 229 
as cause, 90 

diagnosis in presence of, 113 
Stroma of prostate, 29 
Structure of prostate, 28 
Subpubic urethra, curve of, 131 
Suprapubic cystotomy, history of, 7 
drainage-tubes, 173 
fistula, history of, 8 

treatment by, 166 
prostatectomy, advantages of, 206 
history of, 11 
in dogs, 28 
technique of, 219 
puncture, 7, 157, 160 
Surgical anatomy of prostate, 37 
kidneys, 80 

prevention of, 146 
treatment of, 162 
Symptoms, anorexia, 98, 106 
bloody urine, 97 
calculus, 98 
cardiac, 98 
coma, 98 
constipation, 98 
convulsions, 98 
cystitis, 96 

distended bladder, 100 
dribbling of urine, 94 
dropsy, 98 
dyspnoea, 97 

frequency of urination, 92 
haematuria, 97 
haemorrhoids, 98 
heart failure, 98 
hiccough, 97 

incontinence of urine, 95 
kidney breakdown, 97 
loss of sexual power, 98 
objective, 100 
obstipation, 98 
overflow from retention, 95 
painful coitus, 98 
priapism, 98 
renal failure, 97 
retention of urine, 95 
sequence of, 108 
somnolence, 98 
starting stream, 94 
subjective, 92 
uraemia, 97 

vertical dropping of urine, 94 
vomiting, 97 
Syms's prostatic tractor, 16, 239 

Plates XCVIII, XCIX 



Index. 



265 



Tapping the bladder, 7, 153, 156, 160 
Technique, operative, 215 

Goodfellow's operation, 231 
perineal prostatectomy, 231, 238 
Proust's operation, 232 
suprapubic prostatectomy, 219 
Young's operation, 236 
Testicles, internal secretion of, 88 

relation of, to prostate, 88 
Thompson's instruments, Plate IV 

operation, 8 
Tractor, prostatic, DePezzer's, 16, 233 
Syms's, 16, 239 

Plates XCVIII, XCIX 
Young's, 16, 237 

Plates XCIV, XCV, XCVI 
Transversalis fascia, 30 
Transverse perineal muscles, 39 
Treatment, 121 

after perineal prostatectomy, 235, 

237, 241 
after suprapubic prostatectomy, 228 
by Bottini operation, 176 
castration in, 195 
catheterism in, 128 
constitutional, 121 
dietetic, 124 
drugs in, 125 
hygienic, 121 
local palliative, 166 
of complications, 147 
of retention of urine, 154 
prostatectomy, 200 
radical, indications for, 200 
ventrosuspension of bladder, 53 
Trendelenburg position, 219 
Triangular ligament of perineum, 38, 39 
Tuberculosis, vesical, differential diagnosis 

of, 115 
Tumors, prostatic, 63 

formation of, 67 
Tunneling the prostate, 2, 3 

Plate I 
Turkey, enlargement of prostate in natives 
of, 85 



Urachal fistulae, 9 
Uraea, quantity of, 106 
Uraemia, prevention of, 146 

symptom of enlargement of prostate, 

97 
treatment of, 162 

after operation, 230 
Ureters, changes in, 79 
Plate LVIII 
embryology of, 2 1 
muscles of, 45 
surgical relations of, 41 



Urethra, artificial, 9, 169 
changes in, 72 

curve of, in enlargement of prostate, 74 
direction of, in enlargement of prostate, 

74 

grooving anterior surface of prostate, 

23> 30 
length of, 40 
prostatic, 29 

histology of, 36 
resection of floor of, 234, 240 
suture of, after Proust's operation, 

23S 
Y-shaped, 74, 77 
Urethral orifice, elevation, of, 74 

shape of, 76 
Urethral prostatotomy, 5 
Urethritis, as cause, 90 

in dog, 28 
Urinalysis, 106 
Urinary extravasation, 221 
fever, prevention of, 141 

treatment of, 162 
fistula, history of, 8 

treatment by, 166 
retention, causes of, 81, 82 
prevention of, 141 
symptom of enlargement of pros- 
tate, 95 
treatment of, 154 
varieties, 141 
Urination, difficulty in starting, 94 
effects on, 81 
frequency of, 92 
in knee-chest position, 123 
intermittent, 94 
nocturnal, 93 
prostate during, 44 
Urine, acid, drugs for, 128 
alkaline, 80 

drugs for, 127 
amount of, in prostatic urethra, 102 
bloody, 80, 81 
casts in, 106 
changes in, 80 

difficulty in starting stream, 94 
dribbling of, 94 
examination of, 106 
in cystitis, 80 
incontinence of, 95 
medication for, 127 
quantity of, secreted, 106 
residual, 76, 80 

prevention of, 143 
treatment of, 154, 157 
retention of (see Urinary retention) . 
specific gravity of, 106 
vertical dropping of, 94 
Urogenital sinus, 21 



266 



Index. 



Uterus masculinus, 29 

embryology of, 21 
histology of, 36 

Uvula vesicae, 45 



Valves in veins of prostatic plexus, 32 
Varicose veins in prostatic plexus, 82 
Vas deferens, ampulla of, 41 

relation of developement of prostate to, 
27 
Vasectomy, 17, 89 
Vein, dorsal, of penis, 32, 38 
Veins of prostate, 32 

Venous engorgement of pelvic structures, 82 
Ventrosuspension of bladder, 53 
Verumontanum, 29, 45 
Vesical floor, descent of, 76 

insufficiency, cause of, 65 
Vesico-prostatic artery, ^ 
Vomiting as symptom, 97 



Walker's lymph-nodes, 36 
Watson's perineal tube, 176 

Plate LXX 
Weight of normal prostate, 28 
White line of pelvic fascia, 30 
Wolffian bodies, 20 
ducts, 20 



Y-shaped urethra, 74, 77 

Plate LII 
Young's instruments for Bottini operation, 
6, 190 
Plate LXXII 
operation of perineal prostatectomy, 
236 



Zuckerkandl's incision, 14 



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,HS R . ARY 0F CONGRESS 

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